Ellie Elliott

Analysis of Cost Avoidance From Pharmacy Students' Clinical Interventions at a Psychiatric Hospital

Objective. To analyze the cost avoidance resulting from clinical interventions made by pharmacy students completing an advanced pharmacy practice experience (APPE) at a psychiatric hospital. Methods. A retrospective database review of documented clinical interventions by pharmacy students was conducted to classify interventions by type and significance. Interventions were assigned a cost avoidance value determined by an evaluation of the literature. Results. Three hundred-twenty interventions were documented by 15 pharmacy students during the 1-year study period. The majority of interventions were related to psychiatric medication classes and most (n = 197; 61.6%) were classified as being of moderate significance. The most common interventions included patient education (13.1%), order clarification (11.6%), therapeutic dosing adjustments (10.9%), and laboratory order monitoring (8.8%). The estimated cost avoidance from all interventions made by pharmacy students was approximately

Ramelteon: A Novel Approach in the Treatment of Insomnia

23,000. Conclusions. Pharmacy students completing APPEs at a psychiatric hospital contributed to a variety of significant clinical interventions and provided considerable cost avoidance value to the institution.

Adverse Drug Reactions: A Retrospective Review of Hospitalized Patients at a State Psychiatric Hospital

Objective: To review the pharmacology, pharmacokinetics, efficacy, and safety of ramelteon in the treatment of primary insomnia in adults, including elderly adults. Data Sources: MEDLINE (1966–July 2008) and PsyclNFO (1985–July 2008) literature searches were conducted to idontify clinical data involving ramelteon. The manufacturer provided a summary of clinical data and abstracts of unpublished studies. Study Selection And Data Extraction: All primary literature, including abstracts, focusing on the pharmacology and pharmacokinetics of ramelteon and clinical trials evaluating its use was reviewed. Information deemed most relevant was incorporated. Our search revealed 5 controlled trials evaluating the short-term efficacy and safety of ramelteon in the treatment of primary insomnia: 3 in adults and 2 in geriatric patients. Additionally, 2 studies in abstract form that evaluated the long-term effects of ramelteon were included. Data Synthesis: Ramelteon is the first selective melatonin receptor agonist approved by the Food and Drug Administration. It has no affinity for the γ-aminobutyric acid receptor complex or for receptors that bind acetylcholine, cytokines, dopamine, norepinephrine, neuropeptides, opiates, and serotonin. In the only published Phase 3 trial in adults, investigators found that latency to persistent sleep decreased with ramelteon to 31.5 ± 2.91 minutes with 8 mg and 29.5 ± 2.96 minutes with 16 mg compared with 42.5 ± 2.97 minutes with placebo (p = 0.007 and p = 0.002, respectively). Total sleep time was not significantly different from that with placebo. Safety data from short-term studies showed advantages of ramelteon over other sleep agents including no potential for abuse, no rebound insomnia, and lack of effect on motor and cognitive function. The adverse effects seen most frequently in ramelteon clinical trials were headache, somnolence, fatigue, nausea, dizziness, and insomnia. The overall incidence was similar to that of placebo. Conclusions: Ramelteon offers a novel mechanism of action for the treatment of insomnia. Studies support its short- and long-term use in adults and elderly adults for the treatment of primary insomnia characterized by difficulty with sleep initiation. Efficacy studies comparing ramelteon with other sleep agents are needed to further solidify the role of ramelteon in the treatment of insomnia.

Inconsistency in risperidone long-acting injection steady-state plasma levels when switching from deltoid to gluteal administration.

Background There is a paucity of information regarding adverse drug reactions (ADRs) in psychiatric patients. Information on common and preventable ADRs (pADRs) in psychiatric patients will allow for targeted improvement projects. Objective To characterize reported ADRs and pharmacist interventions to prevent ADRs in an extended-care state psychiatric hospital. Methods Four years of ADR reports were assessed for probability, reaction severity, pharmacological class of medication involved, preventability, change in therapy, and transfers to a medical facility. The pharmacist intervention database was queried for interventions classified as “prevention of ADR.” The interventions were assessed for type of medication and recommendation acceptance. Results Medication classes responsible for ADRs included mood stabilizers (30%), typical antipsychotics (25%), atypical antipsychotics (25%), and antidepressants (8%). Nine percent resulted in transfer to a medical facility. Of all ADRs, 34.4% were pADRs; mood stabilizers (41%) and atypical antipsychotics (27%) were the most common pADRs. The most common causes of pADRs were supratherapeutic serum concentrations, drug-drug interactions, and history of reaction. There were 87 pharmacist interventions that were classified as “prevention of ADR,” and the acceptance rate of pharmacists’ recommendations was 96.5%. Mood stabilizers (20%), atypical antipsychotics (17%), and typical antipsychotics (11%) were commonly associated with prevented ADRs. Lithium accounted for 13.8% of prevented ADRs; these ADRs were most often due to a drug–drug interaction with a nonsteroidal anti-inflammatory drug. Conclusions ADRs were most commonly associated with mood stabilizers and antipsychotics, and pADRs were common. There is an opportunity to provide education to medical staff on therapeutic drug monitoring and drug–drug interactions for these classes, particularly lithium.

Plasma Insulin Level Correlation to Metabolic Parameter Shifts in Hospitalized Psychiatric Patients

721 2010 50 721-724 R long-acting injection (RLAI) is a second-generation antipsychotic (SGA) administered intramuscularly every 2 weeks for the treatment of schizophrenia. RLAI is the first SGA to come to market in the United States as a long-acting injectable dosage formulation targeted to improve medication adherence. RLAI is an aqueous suspension of microspheres containing risperidone in a copolymer matrix. The copolymer undergoes gradual hydrolysis at the injection site to allow a slow and steady release of risperidone over a period of several weeks, resulting in stable plasma concentrations of risperidone and its active metabolite, 9-hydroxy-risperidone. The release profile of RLAI following a single intramuscular injection consists of a small initial release of drug (<1% of the dose), followed by a lag time of approximately 3 weeks. The main release of drug begins in the third week and is maintained from week 4 to 6 and subsides by week 7. Steady-state plasma concentrations are achieved after 4 injections. Following multiple doses of RLAI, plasma concentrations of risperidone and 9-hydroxy-risperidone demonstrate linear kinetics. At the time RLAI was initially approved in 2003, it was approved only for gluteal muscle (GM) injection. In October 2008, the drug received approval for deltoid muscle (DM) administration. It is thought that DM injection may be preferred over GM injection by many patients and clinicians and allows for a choice between administration sites, thus potentially increasing patient acceptance. A literature search was performed to validate this claim, which produced no publications directly addressing patient or clinician preference for one injection site over another. Regardless, many patients will be switched from RLAI GM to DM administration, and under some circumstances, some patients may be switched from DM to GM administration. Although one study demonstrated that GM and DM injections of RLAI were bioequivalent routes of administration and thus interchangeable, we report a case of a patient switched from DM and GM injection resulting in inconsistent risperidone and 9-hydroxy-risperidone levels. To our knowledge, this is the first case reporting a difference in steady-state levels between RLAI DM and GM administration.

Utilization of antipsychotic therapeutic drug monitoring at a state psychiatric hospital

Objective To identify potential correlations between baseline plasma insulin level and shifts in metabolic status in psychiatric inpatients. Methods A population of 75 patients was identified for this single-center, retrospective study conducted at a state psychiatric hospital in Kansas City, Missouri. Patients were selected on the basis of presence of a baseline fasting plasma insulin level drawn at admission; duration of stay ≥ 12 weeks between August 1, 2013, and December 31, 2015; and presence of metabolic laboratory and weight measurements at baseline and 3 months. Total initial plasma insulin level (≥ 19 µIU/mL or < 19 µIU/mL) was compared to shifts in metabolic laboratory measurements and weight. A secondary analysis was performed to detect association between the numerical values of assessed parameters and the numerical values for plasma insulin measurements. Results The primary analysis found no correlation between plasma insulin level and changes in any metabolic parameter category at 3 (n = 75) or 6 months (n = 30) after admission. Secondary analysis found significant correlations between the numerical values of baseline total plasma insulin level and fasting plasma glucose level at baseline (r = 0.492, P < .001), 3 months (r = 0.247, P = .035), and 6 months (r = 0.723, P < .001). Secondary analysis demonstrated a significant correlation between baseline total plasma insulin level and hemoglobin A1c values at baseline (r = 0.329, P = .004), 3 months (r = 0.455, P < .001), and 6 months (r = 0.517, P = .003). Conclusions Baseline total plasma insulin levels were strongly correlated with parameters affected directly by alterations in glucose up to 6 months after admission but were weakly correlated or not correlated with other metabolic parameters. The results do not support routine use of plasma insulin as a predictor for shifts in metabolic parameters in patients receiving antipsychotic medications.

Effectiveness evaluation of a pharmacist-driven monitoring database for tardive dyskinesia.

Introduction: This study assesses the utilization of antipsychotic therapeutic drug monitoring (TDM) and describes characteristics of appropriate and inappropriate TDM at a state psychiatric hospital. Methods: A retrospective, descriptive review was conducted for antipsychotic TDM completed between December 1, 2009, and June 30, 2011, at a 65-bed adult inpatient extended-care and forensic state psychiatric hospital. Results: One hundred thirty-three (n = 133) antipsychotic serum levels were collected from 44 patients during the study period. Sixty-nine percent (69%) of the TDM were deemed inappropriate, 28% were appropriate, and 3% could not be designated appropriate or inappropriate owing to the lack of information regarding steady-state conditions. The primary reason for inappropriate TDM was lack of documentation with regard to the indication for TDM (n = 79, 59.3%), the intervention following laboratory analysis (n = 88, 66%), or both. Appropriate TDM was associated with a lower laboratory cost for antipsychotic serum level (

Cost-avoidance and qualitative analysis of clinical pharmacy interventions by psychiatric pharmacy residents at state psychiatric facilities

48.98 ±

Original Article Effectiveness Evaluation of a Pharmacist-Driven Monitoring Database for Tardive Dyskinesia

53.49 versus

Original Article Adverse Drug Reactions: A Retrospective Review of Hospitalized Patients at a State Psychiatric Hospital

72.06 ±