Evaluation of the Impact of Pharmacist-Driven Physician Naloxone Training on an Inpatient Psychiatric Unit

OBJECTIVES

The purpose of this study was to evaluate the impact of pharmacist-driven naloxone training of resident physicians as part of discharge prescribing from an inpatient psychiatric unit.

METHODS

This is a prospective pilot study in which psychiatric resident physicians (N = 21) were educated on naloxone administration, prescribing, and counseling. A ten-question survey was designed and delivered immediately pre- and post-training to assess resident knowledge of and comfort with naloxone prescribing. Respondents were asked to rate ten statements on a scale from 1 to 5, with 1 corresponding to "strongly disagree" and 5 corresponding to "strongly agree." The primary objective was to evaluate the impact of training on prescriber knowledge and attitudes using the designed questionnaire. The secondary objective was to assess the difference in naloxone prescribing pre- and post-training implementation. Descriptive statistics and paired t-tests were conducted to assess statistical significance.

RESULTS

Prior to training, 11 resident physicians (approximately 50%) agreed or strongly agreed that they felt knowledgeable about naloxone and approximately 70% (n = 15) felt confident identifying patients who would benefit from naloxone at discharge. Only 10% of resident physicians (n = 2) felt comfortable counseling patients on and administering naloxone during an overdose pre-training compared to 100% after training. Thirty-seven patients were discharged and counseled on naloxone use during the study period.

CONCLUSION

Pharmacist-driven naloxone training significantly increased physician knowledge and comfort prescribing naloxone and resulted in an increase in naloxone prescriptions upon discharge from an inpatient psychiatric unit.

Evaluation of anxiety in doctor of pharmacy students in their first through fourth professional years

INTRODUCTION

Doctor of pharmacy (PharmD) student anxiety is not well accounted for in the literature. Anxiety carries the potential to cause impairment in functioning, worsen mental health outcomes, and adversely impact cognition, academic performance, and professionalism. The purpose of this study was to characterize anxiety among PharmD students in their first through fourth professional years. Secondary aims were to compare the prevalence of clinically significant anxiety and severity of anxiety among classes.

METHODS

A cross-sectional, observational analysis was performed surveying 198 pharmacy students completing professional coursework. A survey shared via social media containing the Zung Self-Anxiety Scale and general demographic questions was distributed to pharmacy students to assess the prevalence and severity of anxiety in first through fourth professional year students. Clinically significant anxiety was defined as a raw score ≥ 36. A one-way analysis of variance was performed to compare the means of all classes and Tukey's honestly significant differences test was performed to evaluate for statistical differences between individual classes.

RESULTS

Clinically significant anxiety was evident in 65% of respondents. The second professional year class reported the highest rate of anxiety with 84% meeting the threshold for clinically significant anxiety. The fourth professional year class reported the lowest rates with 51% reporting clinically significant anxiety.

CONCLUSIONS

Anxiety is prevalent in pharmacy students with higher levels of anxiety observed in earlier years. This work highlights opportunities to expand student mental health resources. Further studies are warranted to identify factors contributing to pharmacy student anxiety.

Intranasal esketamine: A novel drug for treatment-resistant depression

PURPOSE

To review the efficacy, safety, and place in therapy of intranasal esketamine, a treatment modality for treatment-resistant depression.

SUMMARY

An electronic literature search of PubMed, MEDLINE, and the ClinicalTrials.gov and Food and Drug Administration (FDA) websites covering the period April 2015 through June 2020 was performed using the following search terms: esketamine, intranasal esketamine, depression, and treatment-resistant depression. Other resources included review articles and the manufacturer's product labeling. All relevant English-language articles and reports on clinical trials conducted in humans were included. Esketamine (Spravato, Janssen Pharmaceuticals) is an intranasal antidepressant approved by FDA for management of treatment-resistant depression (TRD) in patients with inadequate response to traditional antidepressant therapy. Esketamine is self-administered under the supervision of a healthcare provider and is used as an adjunct to oral antidepressant therapy. Patients are supervised for 2 hours after self-administering the medication to monitor for sedation, dizziness, dissociation reactions, and increased blood pressure. Esketamine has a favorable risk-to-benefit profile, with demonstrated efficacy in reducing depressive symptoms more rapidly than monotherapy with traditional oral antidepressants. Reported adverse effects include sedation, dizziness, dissociation reactions, and blood pressure elevations, but these effects are primarily confined to the 2-hour postdose monitoring window.

CONCLUSION

Patients with moderate to severe depression who are not sufficiently responsive to traditional strategies for managing TRD may benefit from adjunctive esketamine therapy.

Valbenazine and deutetrabenazine: Vesicular monoamine transporter 2 inhibitors for tardive dyskinesia

PURPOSE

The purpose of this review is to summarize the current evidence for valbenazine and deutetrabenazine use for the treatment of tardive dyskinesia (TD).

SUMMARY

A literature search was conducted to gather relevant data regarding the use of valbenazine and deutetrabenazine for TD management. PubMed, MEDLINE, and ClinicalTrials.gov were searched using the following keywords and MeSH terms: valbenazine, deutetrabenazine, tardive dyskinesia, VMAT2 inhibitors, and vesicular monoamine transporter 2 inhibitors. Randomized, double-blind, placebo-controlled trials and meta-analyses published in English from April 2015 to August 2019 were included. Valbenazine 40-80 mg and deutetrabenazine 12-36 mg per day have been evaluated for the treatment of TD. Abnormal Involuntary Movement Scale (AIMS) scores decline similarly (by 2-5 points) with use of either agent. AIMS response rates, defined by a 50% decline in symptoms, range from 33% to 50%. Both agents are well tolerated, with somnolence and akathisia reported most frequently (at low rates). Agent selection may be guided by manufacturer labeling recommendations for special populations and cost considerations.

CONCLUSIONS

Valbenazine and deutetrabenazine were demonstrated to be effective in decreasing AIMS scores and were well tolerated in randomized controlled trials. These treatments may be considered as a next-line option when traditional strategies are not feasible or are ineffective. Head-to-head studies are warranted to decipher if either agent is preferable in terms of efficacy or tolerability.

Risperidone- and paliperidone-induced hepatotoxicity: Case report and review of literature

Purpose

A case of hepatotoxicity likely due to use of risperidone and paliperidone is reported.

Summary

A 23-year-old man with schizophrenia was admitted to an inpatient psychiatric unit after an exacerbation of mental illness secondary to medication nonadherence. During 13 days of treatment with risperidone, the patient’s liver enzyme levels rose sharply, so antipsychotic therapy was switched to oral paliperidone. After a 5-day downward trend in liver enzyme levels, a dose of intramuscular paliperidone was administered to augment oral paliperidone therapy. After 10 days of paliperidone use, abnormally high liver enzyme levels were again noted; both oral and intramuscular paliperidone therapy were discontinued and haloperidol was initiated, with complete resolution of liver enzyme abnormalities within approximately 4 weeks. Scoring of this case using the algorithm of Naranjo et al indicated probable associations between risperidone use and hepatotoxicity (a score of 7) and paliperidone use and hepatotoxicity (a score of 8). To our knowledge, this is the first case report describing a patient who developed hepatotoxicity during risperidone use that did not remit with a switch to paliperidone therapy.

Conclusion

Findings of this case suggest that patients who develop hepatotoxicity with use of risperidone may also do so with paliperidone use; this, in turn, suggests that both risperidone and its metabolite are capable of causing hepatotoxicity. Patients who develop hepatotoxicity in response to risperidone or paliperidone therapy may benefit from treatment with an alternative antipsychotic with a different chemical structure.

Cost Comparison of Atypical Antipsychotics: Paliperidone ER and Risperidone

Purpose: Paliperidone and risperidone are atypical antipsychotics that are structurally and therapeutically similar. Risperidone is metabolized by the liver via cytochrome (CYP) 2D6 to an active metabolite, 9-hydroxyrisperidone. The atypical antipsychotic paliperidone is 9-hydroxyrisperidone formulated separately as an extended-release (ER) tablet and is considerably more expensive than risperidone. The purpose of this retrospective drug utilization review is to evaluate the prescribing patterns of paliperidone ER and evaluate potential cost savings by converting paliperidone ER orders to risperidone at an inpatient psychiatric hospital's formulary. Methods: This retrospective drug utilization review includes 100 patients, older than 18 years old, who were prescribed oral paliperidone ER at an inpatient, psychiatric hospital between January 1, 2017, and June 2, 2017. The data were collected through the electronic medical records. Patients who were prescribed oral paliperidone ER and refused to take paliperidone ER were excluded from the study population. The cost of each patient's oral paliperidone ER pharmacotherapy was calculated using average wholesale prices. An equivalent total dose of risperidone therapy was calculated using a 2:3 paliperidone ER to risperidone conversion. The cost savings were then analyzed by comparing the total costs of paliperidone ER with risperidone therapy. Results: The results indicate that from January through June 2017, approximately 68% of all paliperidone ER utilization was for its approved indication of schizophrenia and schizoaffective disorder. The other 32% of utilization was either off-label or for approved indications of risperidone. The total paliperidone ER therapy cost for 100 patients was approximately $17 000, while the cost of risperidone therapy would be approximately $400 for the same patients over 6 months. Overall, this would provide an estimated cost savings of over $33 000 per year or about $169 in savings per patient. Conclusion: The study analysis demonstrates that there are opportunities for cost savings through therapeutic interchange of paliperidone ER to risperidone.

Intravenous Olanzapine for the Management of Agitation: Review of the Literature

Objective: The purpose of this review is to summarize the current evidence of the off-label use of intravenous (IV) olanzapine and discuss its risks versus benefits for the management of agitation. Data Sources: A literature search was conducted to gather relevant data regarding IV use of olanzapine for the management of acute agitation. PubMed, EMBASE, MEDLINE, and IPA were searched using the keywords and MESH terms: olanzapine, intravenous, IV, off-label, and agitation. Study Selection and Data Extraction: All case reports, and retrospective and prospective studies evaluating the efficacy and safety of IV olanzapine administration for agitation from January 2004 to December 2018 were analyzed. Data Synthesis: Doses from 2.5 to 10 mg given as an IV bolus (maximum dose of 30 mg/d) have been administered. Rescue medications such as droperidol or parenteral benzodiazepines are sometimes coadministered to assist with achieving adequate sedation. Prospective studies demonstrate efficacy similar to droperidol in achieving adequate sedation within 10 minutes and similar time to onset of sedation. Rates of respiratory depression and airway obstruction are low and similar to that of comparative agents, including intramuscular olanzapine. Relevance to Patient Care and Clinical Practice: This review evaluated the off-label use of IV olanzapine to manage agitation based on case reports, and retrospective and prospective data. Conclusions: The use of IV olanzapine remains controversial in the absence of clear evidence evaluating safety and efficacy. Future studies are warranted comparing IV olanzapine with more commonly utilized and Food and Drug Administration–approved treatment modalities for acute agitation in the emergency department and other settings.

Pharmacist's Role in Improving Medication Adherence in Transplant Recipients With Comorbid Psychiatric Disorders

Medication nonadherence rates are high in both the transplant and psychiatric populations. The consequence of medication nonadherence posttransplant is graft rejection and psychiatric decompensation, highlighting the importance of optimizing adherence to medication regimens. Pharmacists may work with transplant patients with psychiatric comorbidity to improve medication adherence through identifying patient-specific barriers and recommending an appropriate intervention. Multiple evidence-based practices for improving nonadherence have been detailed in the transplant and psychiatric population. Medication adherence aids, medication management, patient education, and motivational interviewing are all strategies that may be used to improve adherence. Selecting which interventions to make will be based on the reasons for a patient's nonadherence. Most patients benefit from medication management, patient education, and medication adherence aids. Selection of medication adherence aids may be based on patient demographics, technology literacy, and preference. Motivational interviewing may be considered in patients with intentional nonadherence relating to a lack of insight into their illness or the importance of taking medication. Pharmacists may promote adherence and potentially improve patient outcomes in transplant recipients with comorbid psychiatric disorders through assisting patients with designing a tailored medication adherence plan.

Depression in Chronic Kidney Disease and End-Stage Renal Disease: Similarities and Differences in Diagnosis, Epidemiology, and Management

Depression is highly prevalent and is associated with poor quality of life and increased mortality among adults with chronic kidney disease (CKD), including those with end-stage renal disease (ESRD). However, there are several important differences in the diagnosis, epidemiology, and management of depression between patients with non-dialysis-dependent CKD and ESRD. Understanding these differences may lead to a better understanding of depression in these 2 distinct populations. First, diagnosing depression using self-reported questionnaires may be less accurate in patients with ESRD compared with CKD. Second, although the prevalence of interview-based depression is approximately 20% in both groups, the risk factors for depression may vary. Third, potential mechanisms of depression might also differ in CKD versus ESRD. Finally, considerations regarding the type and dose of antidepressant medications vary between CKD and ESRD. Future studies should further examine the mechanisms of depression in both groups, and test interventions to prevent and treat depression in these populations.

Bapineuzumab, an investigational agent for Alzheimer's disease

Bapineuzumab for Alzheimer’s disease