Medication maintenance phase

Aikens JE, Nease Jr DE et aL (2005) Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication. Ann Fam Med 3 23-30 Blenkinsopp A, Bond C, Britten N (1997) From compliance to concordance. Achieving shared goals in medicine taking. Royal Pharmaceutical Society of Great Britain and Merck Sharpe Dome, London UK... 

Maintenance Phase Treatment. Because panic disorder tends to be a chronic condition, the appropriate duration of therapy is a critically important question. Conventional practice is to continue treatment for 6-9 months after remission has been achieved and then to taper medicines gradually over several weeks to months. The relapse rate is extremely high with over one-half of those treated with medications alone experiencing a relapse within a few months of discontinuing treatment. There is some evidence that CBT may reduce this relapse rate. When relapse occurs, it is usually advisable to restart the medication that was previously used. 

Maintenance Phase Treatment. OCD is typically a lifelong disorder that rapidly recurs when treatment is discontinued. Consequently, maintenance therapy lasting at least 1-2 years is recommended for all patients with OCD. During medication discontinuation, periodic CBT sessions are commonly used to increase the likelihood of sustained remission. Long-term pharmacotherapy is recommended after only two moderately severe episodes of OCD. 

After the patient has been asymptomatic for a period of approximately 6-12 months (continuation phase), the clinician has to decide who should receive maintenance therapy, which therapy to use, and for how long. The main goal of the maintenance phase is to prevent recurrences. This phase may last from 1 year to much longer, and is typically conducted at a visit frequency of every 1 to 3 months, depending on the patient s clinical status, functioning, support systems, environmental stressors, and motivation for treatment, and the existence of other psychiatric or medical disorders (Fig. 36.4). 

The third phase of treatment is called the maintenance phase. As mentioned earlier, recurrence (the reappearance of symptoms reflecting a new episode) is the hallmark of many depressions (see Table 3.15). This pattern dictates the clinical strategy. If the patient has completed treatment for a first episode ever, most physicians—cognizant of the fact that the lifetime recnrrence risk is approximately 50%—will discontinue medication once a year has been completed. This appears the sensible... 

Baseline and follow-up laboratory tests are required for some medications to monitor for adverse effects. Serum drug concentrations (applicable for lithium, carbamazepine, and valproate) help to adjust the dose and are used for both the acute and maintenance phase of treatment. 

In using medication as a treatment modality, there are three courses of therapy that are usually identified acute, continuation, and maintenance (Gitlin, 1996). Acute treatment addresses the symptoms of an active problem or disorder such as taking lithium to reduce the active symptoms of mania. The continuation phase is designed to prevent relapse. The last course of therapy is maintenance. In the maintenance phase, prevention is emphasized, and medications are used as needed or as symptoms arise (acute treatment), or they can be given to prevent recurrences of the disorder (maintenance treatment). In maintenance treatment, a client is often encouraged to take ongoing doses of the medication to prevent a recurrence. 

The Medical Maintenance Phase focuses on patient s eligibility ... 

The medical maintenance phase of an opioid treatment program requires that the patient be in continuous treatment for how long a period of time ... 

Relapse prevention with medication has been studied in BN as well as AN. In 1991 Walsh et al. placed bulimics who had a 50% or more reduction in binge eating on desipramine in maintenance treatment. About half of the patients relapsed below the 50% reduction within 4 months, despite continued use of the medication. In a second multicenter collaborative study examining the efficacy of fluoxetine maintenance in bulimic patients who had responded to the drug with a 50% reduction of symptoms, the patients who were maintained on the active drug were significantly less likely to relapse than those who were switched to placebo at the end of the acute treatment phase (Romano, 1999). 

Furthermore, most psychiatric disorders are chronic, although some may go through intervals of apparent remission (e.g., major depressive disorder), whereas others are persistent but relatively asymptomatic (e.g., schizophrenia) with effective treatment. Flence, treatment with psychotropics is best considered in terms of months or years of continuous or intermittent therapy, rather than a few days or weeks. By contrast, the vast majority of the clinical trials involve short-term use. Thus, a typical database for the approval of a new antidepressant is usually based on experience with 2,000 to 8,000 patients (carefully selected as described earlier), with the majority exposed to the medication for less than 2 months. Often less than 25% will have received medication for more than 4 months, and less than 10% for more than 6 months. When a drug is marketed, most patients will be exposed to it for a minimum of 4 to 6 months. Yet, when treatment goes beyond 2 months, the database on the safety and continued efficacy of a medication is modest at best. Thus, although clinicians commonly use psychotropics for both maintenance and prophylactic purposes, an approved drug only has to be shown effective in the acute phase. 

Cost, in this context, implies more than just the price of the medication and the services of the treating clinician. Because most psychiatric disorders are chronic conditions, the cost of treatment must take into consideration the acute, maintenance, and prophylactic phases. 

After inducing remission from an acute depressive episode, the next phase of treatment is preventing a relapse back into that episode. The period of highest vulnerability for a relapse is the first 6 to 9 months after the induction of a remission. For that reason, it is advisable to maintain the patient on the medication at full dose at least during this interval. This phase of treatment has been termed either maintenance or continuation treatment. Antidepressant treatment after this interval (i.e., prophylactic therapy ) is generally reserved for patients who have a substantial risk of recurrent episodes. 

Combinations of valproic acid with other psychotropic medications likely to be used in the management of either phase of bipolar illness are generally well tolerated. Valproic acid is an appropriate first-line treatment for mania, although it is not clear that it will be as effective as lithium as a maintenance treatment in all subsets of patients. Many clinicians advocate combining valproic acid and lithium in patients who do not fully respond to either agent alone. 

The early phase of SBS is associated with large day-to-day variations in fluid and electrolyte losses. Strict output records should be assessed, as well as all intake including intravenous medications. Initially, it is recommended to start a standard PN solution that meets the patient s maintenance metabolic, fluid, and electrolyte needs, and a separate intravenous replacement solution is typically necessary to keep the patient euvolemic based on actual fluid losses. Insensible losses should be estimated between 300 and 800 mL/day above measured output, and daily urine output should be kept at least 1 L. As fluid and electrolyte losses stabilize over time it becomes possible to incorporate these replacement requirements into the PN solution. The PN solution typically is composed of standard crystalline amino acids, glucose, and intravenous lipids. A generic caloric breakdown for SBS patients based on a need of 30 to 40 kcaV kg per day may be 1.5 g/kg of protein per day, approximately 20% to 30% of calories from intravenous lipids, and the remainder of calories from carbohydrates. An example of a PN formula for the patient with SBS is given in Table 139-2. 

Thus, this phase is the transition from the area of engineering to the medicine, which will introduce and incorporate the medical equipment on the market. It would make the products more safety, use and maintenance technical specifications relevant and produced regarding the language for the health professional user and associated with the clinical and technical validation that results in the product performance [15, 18, 30]. 

Patients were then advanced to a double-blind phase of the trial which consisted of a 12-week maintenance period, during which time patients study medication. A total of 588 patients who received tapentadol ER in the open-label period had a mean decrease in pain intensity from 7.3 (standard deviation, SD = 1.43), or severe pain, to 3.5 (SD = 1.89), or mild pain, during open-label treatment. During the double-blind period, the tapentadol ER group had an average pain intensity that remained relatively con-stant, while the placebo group had a pain intensity that increased in severity (P < 0.001). 

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