Shrinks In Sneakers

Tag: psychotropics

  • Intramuscular Medication (IM) in Psychiatry: Is it Better?

    Intramuscular Medication (IM) in Psychiatry: Is it Better?

    Intramuscular medication as the name implies is a long-acting injectable form of medication that is usually administered into the gluteal muscle or deltoid muscle and it’s designed to take the place of PO or oral formulations.

    The medications available in IM formulations: 

    • Aripiprazole (Abilify Maintena) 
    • Aripiprazole lauroxil (Aristada) 
    • Fluphenazine (prolixin)
    • Haloperidol (Haldol)
    • Olanzapine pamoate (Zyprexa Relprevv) 
    • Paliperidone (Invega Sustenna, Invega Trinza) 
    • Risperidone (Risperdal Consta) 

    Most last between 2-4 weeks but medications like Invega trinza lasts up to 3 months 

    This solves one of the major issues when prescribing medication, which is adherence with treatment. 

    Notice that all these medications are first- or second-generation dopamine blockers. These medications are commonly used to treat disorder like Bipolar and Schizophrenia (serious mental illness). These populations often have difficulty with medication adherence. 

    Clinically most psychiatrists will tell you IM medication improves patient outcomes. However, they may not outperform PO medication taken daily and consistently. Where these medication formulations have the biggest impact is for people who had improvement on oral medication but often forget to take medication or do not want to take medication daily. Many patients with serious mental illness stop taking medication when symptoms resolve making relapse likely. 

    Side effects will be similar to the oral medication with the added logistical issue of coming to the office for the injection, and pain at the injection site. Normally we assess tolerability and risk of side effects with oral medication before giving IM medication. This avoids the potential for long lasting side effects. 

  • Immediate Release Vs Extended-Release Formulations in Psychiatry

    Immediate Release Vs Extended-Release Formulations in Psychiatry

    Highlights From the Video

    Immediate release the medication is released immediately and results is quick onset and a peak blood level. This type of formulation is generally less expensive and may be advantageous in some cases. For example, if you are using quetiapine at night in part for its sedating effects, I will use immediate release because I want a rapid effect. The same with methylphenidate or bupropion. 

    The problem is this formulation requires twice a day or even three times per day dosing and results in more peaks and troughs. In general, for medications that are being used for maintenance you want consistent blood levels and not peaks and troughs.

    With IR formulations, there can be more side effects and addictive potential. We believe it’s the rapid rise in blood levels of the medication that cause side effects and with medications like amphetamines for ADHD it’s the rapid rise in medication levels that can result in euphoria and thus addictive potential.

    Extended release does not change the active ingredient in the medication, rather it provides a different delivery mechanism that slows the release of medication over an extended period of time. This has the opposite effect on blood levels when compared to IR. There will be less peaks and troughs and more sustained blood levels of medication. The advantage is once daily dosing and potentially fewer side effects for the pervious mentioned reasons. 

    The downside is these medications tend to cost more money and some have argued when initiating these medications, a patient who has an adverse reaction will have symptoms longer with XR. Although clinically I’m not sure this is true and will generally use extended release if possible for maintenance medications.

  • Medication Side Effects: “I feel nauseous”

    Medication Side Effects: “I feel nauseous”

    Introduction:

    Did you know that the researchers that conduct drug trials do not ask patients about specific side effects? Rather, they ask a generic question such as “are you having adverse reactions to the medication” the patient then has to self-report any specific side effects they are having. Sometimes physicians during medication management sessions will use a similar question when asking about side effects. Some physicians also make statements when prescribing the medication such as “don’t worry most people do not have side effects with this medication.” This is egregious, considering we know these medications have side effects as all medications do. What I want to do over the next several posts, is discuss the common side effects of SSRIs and what you can do about them. The biggest issue we face with psychiatric medications is adherence, and many times side effects play a role. 

    I want to start with the most common side effects and work our way down. Nausea is one of the early side effects that is disturbing to patients and may result in discontinuation of the medication. Several things can be done to reduce the risk of nausea. 

    Medication Starting Dose and Titration

    One simple step could be to start the medication at the lowest possible dose and titrate slowly. Titrating the dose over one week has been shown to cut the risk of nausea in half. Another potential intervention is to split the dose and give the split dose with separate meals. If possible, use sustained/extended release preparations of the medication. For example, starting a patient on escitalopram 5 mg instead of 10 mg might help reduce the risk of nausea. Another simple change could be the timing of medication administration. Taking the medication after a meal may be helpful. Many patients find that food helps reduce the nausea and most of these medications can be taken with or without food. 

    Ginger Is Good

    If the above interventions fail to help you can consider ginger root. This dietary supplement can be purchased over the counter from your local health food store. Ginger root 550 mg one to two capsules up to three times per day if the slow titration and other intervention are ineffective. 

    If All Else Fails

    Finally, if the nausea does not respond to the above interventions then anti-nausea medications are appropriate. The two most commonly used at ondansetron and Mirtazapine which also blocks 5HT-3 receptors leading to reduced nausea. 

  • Medication Side Effects: Doctor my mouth is a little dry

    Medication Side Effects: Doctor my mouth is a little dry

    Regular Dental Care and Oral Hygiene

    Dry mouth is another common side effect from psychiatric medication. Patients on psychiatric medication often have poor dental care and poor dental outcomes. There is increased incidence of dental caries and oral ulcers in this population. This patient population is also three times more likely to lose all their teeth. Let that sink in for a moment. Now some of this is related to not following the recommended dental hygiene guidelines such as regular cleanings at least every 6-months. Thus, this is the first step in the process. Ensure the patient first has a dentist, and second be sure they are making regular 6-month appointments, and if they have issues with dental health, they should be going for cleanings as often as every 3 months. Oral hygiene is the foundation for the remainder of the interventions.

    Gum, Candy, and Pilocarpine

    Most patients are told to carry a bottle of water around and take frequent sips throughout the day. This does not work. It provides temporary relief, and does not address the underlying issue. You can educate the patient about drinking more water while eating which can help facilitate the swallowing process especially when dry mouth is an issue. Carrying a cup of ice can be helpful but is not convenient. What I prefer is the use of sugarless gum or candy which can be easily carried and chewed as needed. Studies have demonstrated that xylitol containing gum can reduce the levels of Mutans streptococci and lactobacilli in saliva and plaque. This has the potential to reduce the incidence of dental caries, and is an inexpensive option for most patients. I will also recommend as a second line using a mouth wash for dry mouth such as Biotene. If these interventions are not effective a medication to stimulate saliva production such as pilocarpine. In many cases pilocarpine eye drops which act locally is a better option than a medication that acts systemically. 

    Final Words

    Dry mouth is a common side effect patent’s experience but may not always bring to the clinician’s attention. There are interventions to treat this side effect that range from simple interventions like xylitol containing gum to pharmacological interventions such as pilocarpine eye drops. Most patients will experience relief with the above treatments. This highlights the importance of asking about specific side effects so they can be treated early and prevent long term Complications such as tooth loss.