Depot medication

A high risk of relapse is inherent to schizophrenic psychoses. A relapse is often triggered by emotional stress. It is very important to prevent a relapse by either maintaining low-dose oral medication or by switching to a depot antipsychotic. In some cases, this cannot be avoided. Especially when compliance is a problem, a depot medication may help to keep the patient free of psychotic symptoms. Frequently used depot antipsy-chotics are haloperidol-decanoate, fluphenazine-decanoate, and fluspirilene, which are given in relatively low dosages (see Table 41.4). In EOS, relapse prevention is more important than in adulthood, as the majority of patients have not yet finished school or started a professional career. 

To supplement depot medication, oral preparations can be used when early warning signals of an impending relapse occur because the pharmacokinetics of depot preparations require months to reach steady-state (see also Pharmacokinetics/Plasma Levels later in this chapter). By contrast, oral administration brings about an altered steady state in several days. We recommend treating most patients with the minimally effective dose to avoid more serious adverse effects, even at the cost of a few more relapses, provided this strategy does not lead to rehospitalization or produce serious impairment in functioning. 

Kane et al. (266) point out that some studies may not have effectively evaluated the potential benefit of depot fluphenazine. Thus, patients volunteering for such studies are those who might be compliant whether they took oral or depot medications therefore, these studies may underrepresent the noncompliant population. In addition, inasmuch as relapse may not occur for 3 to 7 months after medications have been completely discontinued, a 1-year study period may not be long enough to evaluate the relative effectiveness of a depot versus oral antipsychotic. 

The use of periocular steroids circumvents many of the side effects associated with systemic steroids however, complications may still arise. lOP response is a particular concern, because depot medications cannot be removed easily, as compared with tapering or discontinuing an oral preparation. Cataractogenesis may occur with any steroid preparation with intravitreal corticosteroid implants, the incidence of cataract formation requiring surgery over 2 years is nearly 90%. 

Another great embarrassment under which the Medical Purveyor s Office labors results from the extreme scarcity of proper vessels in which to transmit medical supplies, such as jars, vials glass stoppered bottles, for lack of which, articles called for are sometimes withheld, although on hand at the Purveying Depot. Medical Officers are, therefore, directed to turn over to the Medical Purveyor such empty vials, bottles, jars, jugs, etc. in their possession for which they may have no use. 

Haloperidol, zuclopenthixol, fluphenazine, flupentixol and pipothiazine are available as depot intramuscular injections for maintenance treatment of patients with schizophrenia and other chronic psychotic disorders. Provided the patient is willing to agree to have depot injections, usually by a community psychiatric nurse at intervals of 2-4 weeks, the need to take tablets two or three times a day is removed. Poor compliance with oral medication is the most common cause of admission to hospital with a relapse of schizophrenia. A reduced initial dose of the depot medication should be given, with a review for unwanted effects after 5-10 days. 

Within the area of biological treatments it is especially important to analyze the non-pharmacological factors of psychopharmacology, which include the fact that prescription patterns vary from one ethnic group to another colored patients in the United States receive greater doses of neuroleptic drugs and injectable or depot forms are more frequent than oral medication (Alarcon, 2005) how side effects are perceived and reported are strongly affected by the patient s (culturally... 

Sociocultural, illness, and biological factors affect individual attitudes towards psychotropic medications. Health beliefs or explanatory models, particularly causal attributions regarding the illness and the treatment options afforded within such models, exert a profound influence on patients attitudes and behavior regarding medications (Smith, Lin Mendoza, 1993). Such effects can be subtle and can occur during the course of treatment even if there has been initial successful negotiation about the nature of the illness and treatment. In psychiatric illness little research has been leveled at the personal meaning that patients bring to treatment practices such as electro-convulsive therapy (ECT), oral medications, and depot injections, or to the transition between different administrative routes and types of medications. 

Rosenblatt, D.H. "Environmental Risk Assessment for Four Munitions-related Contaminants at Savanna Army Depot Activity," Technical Report 8110, U.S. Army Medical Bioengineering Research and Development Laboratory, Fort Detrick, Frederick, MD, November 1981, AD A116650. 

Combine it with a daily routine like when waking up, at breakfast, to the 9 o clock news etcetera. Food interactions must be considered (below) Reduce the number of daily intake. Use Depot preparations or medications with longer half-life. 

The reason for the problems is often that the characteristics of the medication are changed. Depot formulation loses its slow release properties with increased peak-and decreased through concentrations. Enteric coating is destroyed with stomach... 

Many drugs are administered as parenterals for speed of action because the patient is unable to take oral medication or because the drug is a macromolecule such as a protein that is unable to be orally absorbed intact due to stability and permeability issues. The U.S. Pharmacopoeia defines parenteral articles as preparations intended for injection through the skin or other external boundary tissue, rather than through the alimentary canal. They include intravenous, intramuscular, or subcutaneous injections. Intravenous injections are classified as small volume (<100 mL per container) or large volume (>100 mL per container) injections. The majority of parenteral dosage forms are supplied as ready-to-use solutions or reconstituted into solutions prior to administration. Suspension formulations may also be used,101 although their use is more limited to a subcutaneous (i.e., Novolin Penfill NOVO Nordisk) or intramuscular (i.e., Sandostatin LAR Depot Novartis) injection. Intravenous use of disperse systems is possible but limited (i.e., Doxil Injection Ortho Biotec). 

If the relapse is due to nonadherence that resnlted from poor insight (either on the part of the patient or his/her friends and family), then an aggressive psychosocial intervention is warranted. Again, it often makes sense to continne the same medication in this scenario. If poor insight remains a problem, then serions consideration should be given to a depot form of antipsychotic. 

Switching from other antipsychotics - The period of overlapping antipsychotic administration should be minimized. When switching patients with schizophrenia from depot antipsychotics, if medically appropriate, initiate quetiapine therapy in place of the next scheduled injection. Periodically reevaluate the need for continuing existing EPS medication. 

In the Expert Consensus survey (Rush and Frances, 2000) the expert clinicians rated newer atypical antipsychotics highest for treatment of schizophrenic patients who are compliant with medication. Risperidone was rated highest of the atypicals, followed by olanzapine. In the case of patients with numerous failed trials with other antipsychotics, the experts voted for clozapine. For patients noncompliant with oral medication, respondents endorsed long-acting depot antipsychotics. Once again, these were impressions based on personal clinical experiences rather than hard empirical data. 

For patients with chronic psychotic symptoms who do not comply with a daily medication regimen, a long-acting depot preparation should be considered after stabilization with oral medication. Fluphenazine, haloperidol, and risperidone are the only long-acting injectable antipsychotic medications currently available in the United States. 

The 2004 Practice Guideline for the Treatment of Patients With Schizophrenia recommends indefinite maintenance treatment for patients who have had at least two episodes of psychosis within 5 years or who have had multiple previous episodes (Lehman et al. 2004). Maintenance therapy should involve the lowest possible doses of antipsychotic drugs, and patients should be monitored closely for symptoms of relapse. If the patient is compliant with treatment, oral medications are usually sufficient. However, if the patient s treatment history suggests that the patient may not reliably take daily oral medication, a long-acting depot preparation may be indicated. 

Lipophilic groups that are not easily hydrolyzed are used extensively for depot preparations, which liberate the active drug molecule slowly, for a period of days or weeks. Steroid hormone palmitates and pamoates, and antimalarial esters (e.g., cycloguanil pamoate, 3.29), can deliver the active drugs over a prolonged time cycloguanil, for example, is released over a period of several months. This can he a great convenience for the patient, especially in areas with remote medical facilities. 

The efficacy of antipsychotics in preventing relapse is supported by at least 35 random-assignment, double-blind studies, which reported the number who relapsed on placebo versus maintenance medication (Table 5-18). A total of 3,720 patients were randomly assigned to either placebo or a neuroleptic (at least 6 weeks with oral therapy or 2 months with i.m. depot treatment), witn 55% on placebo relapsing, compared with only 21 % on maintenance medication. On the basis of the... 

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