9/19/2011 Disclosure
9/19/2011 Disclosure I have no actual or potential conflicts of interest in relation to this presentation. Increase Your Comfort Level with Psychiatric Medications and Learn How to Effectively Counsel your Patients Kelly N. Gable, Pharm.D., BCPP SIUE School of Pharmacy September 24, 2011 Pharmacist Learning Objectives Discuss abnormalities of the mental status exam that may warrant treatment with a psychiatric medication. Review clinical pearls and counseling points for antipsychotics, antidepressants, mood stabilizers, sedativehypnotics, and anxiolytics. Identify barriers to effective medication education within the psychiatric patient population. Describe techniques to enhance communication and patient interviewing skills. Assessment Question #1 During a routine clinic appointment, a patient presents to you with very eccentric attire, talking extremely fast, and frequent. They begin to tell you about their ability to communicate with the deceased and aspirations to become a physician, senator, and preacher. They describe “not sleeping for days.” This patient is displaying symptoms that best represent: 1. 2. 3. 4. Schizophrenia Mania Depression Anxiety Assessment Question #2 Assessment Question #3 You dispense a prescription for asenapine (Saphris®) to a patient taking it for the first time. It is important to counsel the patient on which of the following? While working at the local independent pharmacy, you receive a phone call from the town physician. He is requesting a recommendation for a non-addictive sleep aid for his patient that is depressed. The patient has a history of alcohol dependence and he would like to prescribe something that is not a controlled substance. It would be appropriate for you to suggest: 1. 2. 3. 4. This medication must be placed under the tongue to dissolve sublingually It is necessary to take this medication with at least a 350 calorie meal This medication commonly makes people feel restless, let your prescriber know if you start to feel anxious You will need to get your blood drawn weekly for the first 6 months of treatment 1. 2. 3. 4. Zolpidem Bupropion Temazepam Trazodone 1 9/19/2011 Assessment Question #4 Abnormalities of Mental Status It is important to recognize that an individual with a severe and persistent mental illness is faced with many barriers that may prevent successful treatment. A barrier to treatment adherence that you (the pharmacist) can directly impact daily would be: 1. 2. 3. 4. Co-occurring alcohol dependence Negative stigma associated with mental illnesses Paranoia and auditory hallucinations Homelessness and poverty Abnormalities of Mental Status Appearance: Poor grooming, mismatched dress, hygiene, unshaven, poor dentition Behavior: Difficult to engage, psychomotor slowed, poor eye contact, stooped posture, poor impulse control, abnormal movements (tremor, tics) Speech: Poverty of speech, neologisms, difficulty with word finding, clanging Sara J. is a 45 year old female wearing mismatched clothes, malodorous, presenting to the pharmacy counter window. She is demanding to speak to the pharmacist. “I can’t take this Zyprexa anymore….I’ve gained too much weight!” As you observe her walking up & down the store aisle, she is talking to herself. Abnormalities of Mental Status Mood: Affect: how one displays their mood to you Depressed Dysphoric Euthymic Elevated Euphoric ◦ Restricted ◦ Flat ◦ Is it appropriate? Euphoria Euthymia Depression What is Depression? Abnormalities of Mental Status Thought Process: The expression of one’s thoughts Are they goal-oriented or illogical? Sleep changes Suicidal Appetite changes Depression +/Anhedonia Hopeless Circumstantial Tangential Flight of ideas Loose associations Concrete thinking Thought blocking Poor energy 2 9/19/2011 Abnormalities of Mental Status What is Schizophrenia? Thought Content: Inner beliefs Abnormalities: Positive Symptoms Delusions Suicidality Thought insertion/broadcasting Hypersexuality False perceptions: hallucinations Negative Symptoms Cognitive Symptoms What is Mania/Bipolar Disorder? ↓ Need for Sleep Pressured Speech Flight of Ideas • Flat affect, asocial, amotivation, anhedonia • Impaired attention & memory, poor executive functioning 2nd-Generation Antipsychotics (SGAs) Grandiose, Irritable, or Euphoric • Hallucinations, delusions, disorganization Clozapine (Clozaril®)- 1990 Risperidone (Risperdal®)- 1994 Olanzapine (Zyprexa®)- 1996 Quetiapine (Seroquel®)- 1997 Ziprasidone (Geodon®)- 2001 Aripiprazole (Abilify®)- 2002 Paliperidone (Invega®)- 2006 Asenapine (Saphris™)- 2009 Iloperidone (Fanapt™)- 2009 Lurasidone (Latuda ™)- 2011 Stahl SM, Essential Psychopharmacology: Neuroscientific Basis and Practical Applications 2nd Edition. 2000 Antipsychotic Clinical Pearls Clozapine: 300 – 450 mg/day Benefits: decreases violence & aggression, treats refractory psychosis, reduces suicidal ideation, improves tardive dyskinesia (least likely to cause EPS) Adverse Effects: agranulocytosis (0.5 – 2% incidence), seizure risk, excessive sedation, weight gain, hyperlipidemia, hyperglycemia, tachycardia / myocarditis, cardio/respiratory depression Antipsychotic Clinical Pearls Risperidone vs. Paliperidone Risperidone: 4 – 6 mg/day (can be BID) Smokers may require higher doses (CYP1A2 substrate) Benefits: multiple dosages forms (tablets, ODT- Zydis, short acting & long-acting IM) IM administration with benzodiazepines = severe hypotension Adverse Effects: weight gain, hyperlipidemia, hyperglycemia Paliperidone: 3 – 9 mg/day Olanzapine: 10 – 30 mg/day Dosage Forms: tablet, solution, ODT, long-acting IM (q 2 weeks) T ½: 21 hrs $ Dosage Forms: OROS capsule, long-acting IM (q 4 weeks) T ½: 24 hrs $$$$ Adverse Effects: orthostatis, weight gain, EPS, ↑ prolactin 3 9/19/2011 Antipsychotic Clinical Pearls: ‘the new kids on the block’ Antipsychotic Clinical Pearls Quetiapine: 300 – 800 mg/day Ziprasidone: 80 – 160 mg/day (given BID) Commonly under-dosed (25 or 50 mg q HS) Dosage Forms: IR tabs; ER tabs (break to become IR) Adverse Effects: sedation, weight gain, hypertriglyceridemia, hyperglycemia Bioavailability ↑ 2-fold when given with food Dosage Forms: capsules, short-acting IM (max: 2 x 20 mg doses in 24 hr) IM administration with benzodiazepines = severe hypotension Adverse Effects: insomnia, nausea, headache, QTc prolongation Aripiprazole: 10 – 30 mg/day D2 partial agonist/antagonist Dosage forms: tabs, solution, ODT, short-acting injection Adverse Effects: insomnia, anxiety, akathisia, HA, nausea Antipsychotic: Long-Acting Injections (LAIs) Iloperidone: 1 mg BID Asenapine: 5 mg BID (sublingual tablet) Lurasidone: 40 – 80 mg/day Clinical Pearls Haloperidol 50 mg/mL 100 mg/mL Q 2 – 4 weeks Yes ~ 4 weeks Room temp Sesame oil vehicle More painful injection Fluphenazine 25 mg/mL Q 3 weeks No Room temp Sesame oil vehicle More painful injection Risperidone 12.5, 25, 37.5, 50 mg Q 2 weeks Yes- 3 weeks Refrigerator Hydrophilic microspheres Paliperidone 117, 156, 234 mg Q 4 weeks (must load with 234 mg; then 156 mg 1 week later) No Room temp Prefilled syringes Loading dose $$$ Q 2 – 4 weeks No 210, 300, 405 mg Aripiprazole Room temp Post Injection Delirium Syndrome (must be monitored x 3 hrs post injection) Reduce psychosis, agitation Improved negative & cognitive symptoms Reduce manic symptoms Improved QOL (occupational, social) Minimize/prevent relapse Highlight common adverse effects: Pseudoparkinsonism (resting tremor) Akathisia (internal restlessness) Weight gain, glucose dysregulation Discuss more rare adverse effects: Tardive dyskinesia Hyperprolactinemia Community Pharmacy Prescription: Thought organizer Mood stabilizer Avoid statements such as: Focus on the benefits: Coming soon… Use patient-friendly terminology Hypothesized to possibly improve cognition (5-HT1 partial agonist) Administer with 350 cal meal for full absorption Adverse effects: insomnia, akathisia/restlessness, elevated prolactin, minimal weight gain and cholesterol changes are minimal Antipsychotic Counseling Points Do NOT swallow tablet (bioavailablity <2% if swallowed; 35% sublingually) NO eating or drinking 10 min post dose Antipsychotic Counseling Points Antipsychotic Strengths Administration Oral Storage Overlap Olanzapine Increase to target of 12 – 24 mg/day Similar binding profile (D2/5-HT) to risperidone Adverse Effects: orthostasis, dizziness, sedation, HA, wt gain, nausea Abilify 30 mg q day #30 Not covered by insurance / needs prior authorization What do you do? “You need to take this medication to avoid from going crazy!” “This is an antipsychotic, people take it if they are hearing voices.” “You will likely gain weight with this medication.” 4 9/19/2011 Community Pharmacy Antipsychotic FDA-Indications Schizophrenia Questions to ask? How long has this person been taking Abilify? Is this a new prescription? What is it being used to treat? What happens if the patient misses several doses of their antipsychotic? Are the antipsychotics interchangeable? Bipolar Disorder, acute mania Bipolar Disorder, maintenance therapy Bipolar Disorder, Depression Clozapine* X Risperidone X (≥ 13 y.o.) X (≥ 10 y.o.) X (Risperdal Consta) Olanzapine X (≥ 13 y.o.) X (≥ 13 y.o.) X X (Symbyax) Quetiapine X (≥ 10 y.o.) X (≥ 13 y.o.) X (≥ 10 y.o.) X Ziprasidone X X X (ADJUNCT) Aripiprazole X (≥ 13 y.o.) X (≥ 10 y.o.) X (≥ 10 y.o.) Paliperidone X Asenapine X Iloperidone X Lurasidone X Irritability Associated with Autism Major Depressive Disorder (ADJUNCT) Agitation associated with schizophrenia or bipolar mania X (≥5 y.o.) X (IM) X X (IM) X (≥6 y.o.) X X (IM) X *Treatment resistant & recurrent suicidal behavior associated with schizophrenia Antidepressants Selective Serotonin Re-Uptake Inhibitors (SSRIs) SSRI Clinical Pearls Tri-cyclic Antidepressants (TCAs) Fluoxetine: 20 – 80 mg/day Fluoxetine (Prozac®, Prozac Weekly®, Sarafem®, Symbyax®) Desipramine (Norpramin®) Paroxetine (Paxil®/ Nortriptyline (Pamelor®) Sertraline: 50 – 200 mg/day CR®) Amitriptyline (Elavil®) Fluvoxamine (Luvox®/ CR®) Imipramine (Tofranil®) Citalopram (Celexa®) Clomipramine (Anafranil®) Escitalopram (Lexapro®) Doxapin (Sinequan®) Short t ½ Constipation, dry mouth, sedation more common Fluvoxamine: 50 – 300 mg/day Nausea & diarrhea common Paroxetine: 10 – 50 mg/day Sertraline (Zoloft®) Long t ½ = good for non-adherent patient Insomnia & activation common Clinically used for OCD Citalopram / Escitalopram: 20 – 40 mg/day / 10 – 20 mg/day Newest SSRIs, fewer drug interactions All SSRIs are equally efficacious; better tolerated than TCAs & MAOIs TCA Clinical Pearls Often used for: depression, neuropathic pain, anxiety disorders, & enuresis Poorly tolerated!!: Anticholinergic side effects (dry mouth, urinary retention, blurred vision, constipation) Sedation, weight gain, sexual dysfunction, seizure risk Cardiovascular complications Orthostatic hypotension, tachycardia, cardiac conduction abnormalities Other Antidepressants Trazodone (Desyrel®,Oleptro™) Bupropion (Wellbutrin IR, SR, XL®, Zyban®) Venlafaxine (Effexor®, Effexor XR®) Desvenlafaxine (Pristiq®) Duloxetine (Cymbalta®) Mirtazapine (Remeron®) Vilazodone (Viibryd™) Lethal in overdose 5 9/19/2011 Antidepressant Clinical Pearls Trazodone: 200 – 600 mg/day 25 – 100 mg/day = insomnia treatment No abuse potential, safer in overdose Bupropion: 150 – 300 mg/day IR rarely used; SR BID dosing; XR q day dosing Only dopamine enhancing antidepressant Adverse effects: insomnia, weight loss, NO sexual dysfunction, lowered seizure threshold NOT used with epilepsy, eating disorders, alcoholism SNRIs: may increase diastolic blood pressure OTC/Herbal Antidepressants St. John’s Wort: 300 mg TID Efficacy: placebo < St. John’s Wort = TCA Drug Interactions: CYP2C9, 3A4, 2D6, 1A2 inducer Reports of ↓ serum concentrations of OC, theophylline, warfarin, protease inhibitors Serotonin syndrome risk 5-HTP Efficacy very similar among all 3; commonly used for neuropathic pain Mirtazapine: 15 – 45 mg/day Common use in geriatric depression due to sedation & weight gain Anti-nausea effect http://www.ssrireview.com/Natural_Serotonin_Boosters/Natural_Serotonin_Boosters.php Antidepressant Counseling Points Emphasize the benefits! Importance of adherence → serotonin withdrawal Drug interactions → serotonin syndrome Common adverse effects: HA, nausea, diarrhea Sexual dysfunction How do you counsel on sexual dysfunction? Discontinuation Syndrome Anxiety, agitation, irritability, sleep disturbances, dizziness, nausea, paresthesias Usually occurs 1-3 days after d/c SSRI; lasts up to 2 wks Worse with paroxetine & venlafaxine Minimal with fluoxetine Anorgasmia, delayed ejaculation, ↓ libido, There are treatment options: Dose reduction of antidepressant Drug holiday or timing of dosing Choose another antidepressant: bupropion, mirtazapine For erectile dysfunction: sildenafil (Viagra ) PRN http://thebrain.mcgill.ca/ Serotonin Syndrome: Does this really exist? What do you recommend? SSRIs + MAOIs? SSRIs + dextromethorphan? Phenelzine + meperidine? TCAs + lithium? SSRIs + St John’s Wort? TCA + trazodone? SSRIs + linezolid? Mood Stabilizers Lithium Valproate (Depakote®) Lamotrigine (Lamictal®) Carbamazepine (Tegretol®) Oxcarbazepine (Trileptal®) Atypical Antipsychotics Symptoms: Confusion (mental status Δ), N/V/D, tremor, restlessness, hyperreflexia, HTN, tachycardia, fever, diaphoresis, myoclonus, rigidity 6 9/19/2011 Mood Stabilizer Clinical Pearls Depakote: 1000 – 4000 mg/day Lamotrigine: 100 – 200 mg/day Better for bipolar depression (no anti-manic activity) Dose escalation is slow due to SJS risk (initiate at 25 mg/day) Carbamazepine: 400 – 1600 mg/day Potent liver enzyme inducer In The Hospital Studies have shown efficacy for use in: Better for rapid cycling bipolar disorder Monitor for hepatotoxicity Quicker control of manic symptoms Adverse Effects: GI upset, sedation, weight gain, hair loss Lithium Clinical Pearls Most effective for bipolar disorder, type I (mania) Less effective for rapid cycling / mixed mania NO hepatic metabolism (~100% renal clearance) 0.6 – 1.2 mEq/L = therapeutic (>1.5 mEq/L = toxic) Lithium Counseling Points You are providing discharge counseling for a 25 year old patient taking lithium 300 mg q day and citalopram (Celexa®) 40 mg q day. What are important counseling points? Adverse effects: You routinely see a patient in your clinic for diabetes management. He also has hypertension and hyperlipidemia. He suffers from chronic insomnia. Current medications: Nausea, diarrhea, fine hand tremor, polydipsia & polyuria, “loss of creativity” Increased risk for toxicity: The Outpatient Clinic Bipolar mania & depression Bipolar relapse prevention Unipolar depression augmentation Suicidality prevention Poor renal function, drug rxn (HCTZ, ACEI/ARBs, NSAIDs) Sodium restricted diets (< 2 g/day) Dehydration, heavy exercise, hot weather Vomiting & severe diarrhea Stress importance of regular blood monitoring & outpatient follow-up Contraception for females The Outpatient Clinic Is it appropriate to prescribe a patient a benzodiazepine + zolpidem for insomnia? Metformin 500 mg BID Simvastatin 40 mg q HS Lisinopril 20 mg q day Zolpidem 10 mg q HS Diazepam 10 mg q HS 7 9/19/2011 Benzodiazepines Anxiolytics Clonazepam (Klonopin®) Alprazolam (Xanax®) Lorazepam (Ativan®) Diazepam (Valium®) Clorazepate (Tranxene®) Chlordiazepoxide (Librium®) Oxazepam (Serax®) The Outpatient Clinic Clinical Pearls: Benzodiazepines Metabolism: Lorazepam, oxazepam, & temazepam Short t½ (5 – 14 hrs): oxazepam Intermediate t½ (10 – 20 hrs): alprazolam, lorazepam Clonazepam t ½ ~40 hrs Long t½ (100 hrs): diazepam, clorazepate, chlordiazepoxide DEA Schedule IV All have a relatively fast onset of 15-20 minutes Ambien® & Lunesta® have longer half lives & are better indicated for maintaining full night of sleep Sonata® best for patients having trouble falling asleep Structurally unrelated to BZDs Highly lipophilic: diazepam, alprazolam Clinical Pearls: Non-benzodiazepines Antihistamines (diphenhydramine, hydroxyzine) Natural products (melatonin, valerian) Chloral hydrate Antidepressants (trazodone) Melatonin receptor agonist (ramelteon- Rozerem®) Zolpidem (Ambien®) Zaleplon (Sonata®) Eszopiclone (Lunesta®) Onset of Action: Pharmacokinetics: Which benzodiazepine is most appropriate for the treatment of insomnia vs anxiety? Other Sedative-Hypnotics Bypass major hepatic metabolism: Sedative-Hypnotics Temazepam (Restoril®) Triazolam (Halcion®) Quazepam (Doral®) Estazolam (ProSom®) Flurazepam (Dalmane®) Primarily have sedative properties (NOT anxiolytic, muscle relaxant, or anticonvulsant) Sedative-Hypnotic Counseling Points Timing of dosing Length of treatment Common side effects: dizziness, headache, nausea, psychosis (at higher doses) Trazodone ~30 – 60 min before bed Temazepam ~ 60 min before bed Quetiapine IR ~15 – 30 min before bed Quetiapine XR ~ 2 – 3 hrs before bed Zolpidem ~ 15 – 30 min before bed 6 weeks, 6 months, or long-term? Transient insomnia (from acute stress), short-term, and chronic insomnia Sleep hygiene 8 9/19/2011 Barriers in Medication Education Barriers in Medication Education Stigmatized perception of mental illness Public perceptions of mental illnesses: 71%- due to emotional weakness 65%- caused by bad parenting 45%- victim’s fault; can will it away 43%- incurable 35%- consequence of sinful behavior 10%- has a biological basis; involves the brain Poverty-related factors Complex dosing regimens Internet resources Poor disease insight Co-occurring substance use Active symptoms: Psychosis (paranoia) Amotivation (negative symptoms; depression) Cognitive dysfunctions (memory deficits) No consensus on treatment recommendations among prescribers Pharmacist attitude & behavior (poor communication) Stahl SM, Essential Psychopharmacology: neuroscientific basis and practical applications, 2000. Assessing Adherence & Building Rapport Important questions to ask: Tell me how your medications are helpful to you? Do you think you need all of the medications you are taking? How do your medications make you feel? How often do you forget to take your medications? When you feel better, do you sometimes stop taking your medication? Improving Patient Communication Let the patient discuss their concerns first Listen to patient’s beliefs and attitudes Withhold the urge to contradict or “correct” patient beliefs The patient’s subjective beliefs rather than objective medical reality ultimately influence behavior Be sensitive to cultural beliefs Patients are more likely to be adherent when they experience the clinician as competent, supportive, optimistic, and encouraging Improving Patient Communication Psychoeducation Motivational Interviewing (MI) Directive, person-centered counseling style for eliciting behavior change; helping patients to explore & resolve ambivalence Work within the stages of change Precontemplation:“there is no problem” Contemplation:“there may be a problem, I have mixed feelings about it.” Determination / preparation:“there is a problem & I want to change.” Action → Maintenance Core features of MI Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance Assessment Question #1 During a routine clinic appointment, a patient presents to you with very eccentric attire, talking extremely fast, and frequent. They begin to tell you about their ability to communicate with the deceased and aspirations to become a physician, senator, and preacher. They describe “not sleeping for days.” This patient is displaying symptoms that best represent: 1. 2. 3. 4. Schizophrenia Mania Depression Anxiety 9 9/19/2011 Assessment Question #2 Assessment Question #3 You dispense a prescription for asenapine (Saphris®) to a patient taking it for the first time. It is important to counsel the patient on which of the following? While working at the local independent pharmacy, you receive a phone call from the town physician. He is requesting a recommendation for a non-addictive sleep aid for his patient that is depressed. The patient has a history of alcohol dependence and he would like to prescribe something that is not a controlled substance. It would be appropriate for you to suggest: 1. 2. 3. 4. This medication must be placed under the tongue to dissolve sublingually It is necessary to take this medication with at least a 350 calorie meal This medication commonly makes people feel restless, let your prescriber know if you start to feel anxious You will need to get your blood drawn weekly for the first 6 months of treatment 1. 2. 3. 4. Zolpidem Bupropion Temazepam Trazodone Assessment Question #4 It is important to recognize that an individual with a severe and persistent mental illness is faced with many barriers that may prevent successful treatment. A barrier to treatment adherence that you (the pharmacist) can directly impact daily would be: 1. 2. 3. 4. Co-occurring alcohol dependence Negative stigma associated with mental illnesses Paranoia and auditory hallucinations Homelessness and poverty Questions? kgable@siue.edu (314) 603-5223 10
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