Maintenance phase of treatment

The treatment for ALL consists of three main elements remission induction, intensification (consolidation), and continuation (maintenance) phases of treatment.3 Therapy to eradicate subclinical CNS leukemia is also an integral part of therapy for ALL (Table 92-7). 

As in the continuation phase, the antidepressant that successfully achieved remission should be continued at the same dose during the maintenance phase of treatment. A collaborative decision between patient and physician is crucial to the success of the maintenance phase of treatment. These collaborative assessments should be repeated every 1-2 years and will require exploration of the patient s attitudes toward prolonged treatment. 

Specific Serotonin Reuptake inhibitors (SSRis). To date, the only SSRI studied in AN is fluoxetine (Prozac). During the acute refeeding phase of treatment, fluoxetine shows modest improvement in weight gain while a larger controlled study during the maintenance phase of treatment demonstrated effectiveness in the prevention of relapse. From the standpoint of side effects and toxicity, the SSRIs are clearly... 

There likely remains a role for pharmacotherapy for some AN patients during the maintenance phase of treatment. Appetite stimulants, prokinetics, and anxiolytics should be tapered and discontinued at the conclusion of the acute phase of treatment. However, early evidence suggests that continued antidepressant administration may help to sustain remission. The appropriate duration for maintenance pharmacotherapy in AN has not been well studied and remains open to debate. 

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. 

Maintenance Phase Treatment. The purpose of this phase of treatment is to provide protection against a recurrence of the illness. In contrast to a relapse, a recurrence is the development of a new episode of depression after the complete resolution of a prior episode. Though theoretically defensible, the distinction between a relapse and recurrence is often vague. 

The pharmacological management of bipolar disorder involves treatment of both the acute and the longer-term maintenance phase of the illness. Longterm maintenance is necessary to reduce or prevent the recurrence of the symptoms, and to minimize the risk of suicide. 

During all phases of treatment, education, supportive therapy, and, at times, more specific types of psychotherapy are essential for a satisfactory outcome. For example, interpersonal therapy can complement adequate maintenance antidepressant treatment, possibly diminishing the frequency of episodes (see the section Role of Psychosocial Therapies in Chapter 7), and cognitive-behavioral techniques in combination with antiobsessive agents (e.g., clomipramine) can improve the quality of life for patients with obsessive-compulsive disorder, minimizing time spent on disabling rituals (see the section Obsessive-Compulsive Disorder in Chapter 13). 

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. 

Lithium Plus Antipsychotics. Many patients present in a very explosive, belligerent, and agitated manner, and waiting several days to weeks to gain control of an episode is not feasible. Thus, antipsychotics alone or as adjuncts are frequently required in the earliest phases of treatment, particularly with moderate to severe exacerbations, often associated with psychotic features. As a result, antipsychotics are the most commonly used adjunctive agents, because more than half of all acutely ill bipolar patients present with psychotic symptoms. In addition, many require maintenance antipsychotics to prevent frequent relapses. Antipsychotics are usually initiated in conjunction with lithium because of their more rapid impact, then carefully tapered and discontinued, when possible, after the full effect of lithium is realized. 

Relatively recently intranasal administration of the allergen has been adopted. In particular, specific local nasal immunosensitizing therapy (LNIT) that was first used by Herxheimer [1] in 1951 is based on direct immunotoler-ance induction in the shock organ with a reduced risk of side effects and costs. The standard treatment schedule consists of an induction phase with increasing dosages followed by a maintenance phase. Other treatment schedules consist of a constant dosage [7, 8],... 

U/kg every 2 weeks. The dose of enzyme selected at the initiation of treatment and dtuing the maintenance phases of therapy must be based on objective... 

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... 

It is now common practice, especially with the more recently introduced residual pyrelhruids. to recommend that treatment be given in two phases. An initial higher treatment level to provide clean out of an infestation is followed by a maintenance phase of repeated applications at suitable intervals, where the dosage applied at each re-treat mem is often half that of the initial treatment. 

It is important to screen patients for co-occurring mental disorders, and their presence may become more apparent during the stabilization or maintenance phases of schizophrenia treatment. Examples include substance abuse disorders, depression, obsessive-compulsive disorder, and panic disorder. As co-occurring disorders will limit symptom and functional improvement and increase the risk of relapse, it is critical that they be appropriately treated. Pharmacological and nonpharmacological interventions specific for the co-occurring disorder should be implemented in combination with evidence-based treatment for schizophrenia. 

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

Divalproex sodium is comprised of sodium valproate and valproic acid. The delayed-release and extended-release formulations are converted in the small intestine into valproic add, which is the systemically absorbed form. It was developed as an antiepileptic drug, but also has efficacy for mood stabilization and migraine headaches. It is FDA-approved for the treatment of the manic phase of bipolar disorder. It is generally equal in efficacy to lithium and some other drugs for bipolar mania. It has particular utility in bipolar disorder patients with rapid cycling, mixed mood features, and substance abuse comorbidity. Although not FDA-approved for relapse prevention, studies support this use, and it is widely prescribed for maintenance therapy. Divalproex can be used as monotherapy or in combination with lithium or an antipsychotic drug.31... 

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