Assessment of oral overlap with antipsychotic long-acting injectables initiated in an inpatient setting.

Introduction: Long-acting injectable (LAI) antipsychotics are a promising solution to combating issues related to nonadherence to oral antipsychotics. Oral overlap is utilized when an LAI is initiated to achieve therapeutic concentrations. The place in therapy in which additional overlap is warranted is often mistaken, and providers may prescribe additional overlap based on the presentation of the patient or misunderstanding of appropriate overlap. Methods: This retrospective chart review assesses patients who were initiated on an LAI while admitted to the acute inpatient psychiatric unit from January 1, 2016, to December 31, 2019. The primary outcome assesses the appropriateness of oral overlap with LAIs. Secondary outcomes include adherence to oral overlap, discontinuation of an LAI within 4 months, and reason for discontinuation of LAI. Results: A total of 62 patients were included: 40 (65%) had appropriate overlap, and 22 (35%) had inappropriate overlap. The most common LAI was paliperidone (n = 50, 81%). Patients were adherent to oral overlap in 67% (n = 6) of the appropriate overlap group and 85% (n = 17) of the inappropriate overlap group. Discontinuation of an LAI in 4 months occurred in 62.5% (n = 25) of the appropriate group and 40.9% (n = 9) of the inappropriate group. There were no significant differences in secondary outcomes when comparing adherence to oral overlap (p = .26), discontinuation of LAI within 4 months (p = .62), and reason for discontinuation (p = .69). Discussion: This study identified that a majority of patients had appropriate prescribing of oral antipsychotic overlap.

Assessment of hepatitis C monitoring adherence after viral eradication in veterans with substance use to improve care and surveil reinfection.

Introduction: Hepatitis C virus (HCV) incidence rates are rising for patients with substance use and/or SUDs. Guidelines provide monitoring recommendations to ensure remission after successful treatment. The study's objective was to identify gaps in follow-up for patients with documented substance use and/or SUD through assessment of adherence to guideline-recommended HCV RNA lab 12 months post-treatment. Methods: Patients treated for HCV through the Veteran Health Indiana Hepatitis C Pharmacy Clinic were retrospectively evaluated. Subjects were categorized based on the provider assigned for follow-up care after 12-week sustained virologic response (SVR12) labs (primary care provider [PCP] or HCV provider). The primary outcome was HCV RNA obtained 11 to 13 months post-treatment. Secondary outcomes were HCV RNA detected post-treatment, substance use, engagement in substance use treatment, and engagement with social work. Results: Two hundred forty-one patients were included in the HCV provider cohort and 139 in the PCP cohort. Forty-one patients did not have a specified clinic for follow-up treatment, and 20 patients did not achieve SVR12. Sixty-one patients (28%) in the HCV provider cohort completed a 12-month HCV RNA within 11 to 13 months post-treatment vs 15 patients (11%) in the PCP cohort (P ≤ .01). One patient had HCV RNA detected post-treatment. Discussion: This study reveals inadequate HCV post-treatment follow-up for patients with substance use and/or SUD. SUD is a chronic disease that requires continued monitoring to prevent complications. Further studies are needed to identify reinfection rates and improvements of care in this population.

Relapse rates among veterans on maintenance doses of combination buprenorphine and naloxone for opioid use disorder.

INTRODUCTION: Opioid use disorder (OUD) can cause significant morbidity and mortality with more than 115 people dying from an opioid overdose daily in the United States. Treatment with buprenorphine/naloxone (BUP/NAL) can be effective; however, there is conflicting evidence on the utility of higher doses in preventing relapse. This study was designed to assess BUP/NAL maintenance doses and the rate of relapse in veterans with OUD. METHODS: Patients diagnosed with OUD who received a prescription for BUP/NAL through the substance use disorder recovery program were retrospectively evaluated. Patients were categorized into 2 treatment groups: those prescribed ≤16 mg of BUP/NAL daily and those prescribed >16 mg of BUP/NAL daily. The primary outcome was to determine rates of relapse between maintenance doses of BUP/NAL. Secondary outcomes included evaluating the difference in rates of relapse between daily versus take-home dosing, tablets versus films, time to relapse, and use of illicit substances during treatment. RESULTS: Patients prescribed >16 mg of BUP/NAL daily had statistically significantly lower rates of relapse compared to patients prescribed ≤16 mg of BUP/NAL daily (P = .0018). Regarding secondary outcomes, there was a statistically significant difference in time to relapse (P = .036) and dosage form (P = .0124). Difference in administration of dose and illicit substance use during treatment were not statistically significant. DISCUSSION: This study identified that rate of relapse can be lowered and time to relapse can be lengthened when doses >16 mg of BUP/NAL are prescribed in the veteran population for OUD.

A Multicenter Analysis of Factors Associated With Apixaban-Related Bleeding in Hospitalized Patients With End-Stage Renal Disease on Hemodialysis.

BACKGROUND: In 2014, the United States Food and Drug Administration approved a labeling change for apixaban to include recommendations for patients with severe renal impairment and patients with end-stage renal disease (ESRD) on hemodialysis (HD), though these recommendations are largely based on pharmacokinetic and pharmacodynamic data. OBJECTIVE: Identify variables associated with bleeding events in hospitalized patients with ESRD on HD receiving apixaban. METHODS: This retrospective, multicenter cohort study evaluated hospitalized patients with ESRD on HD receiving apixaban from January 1, 2013, through March 31, 2016. Correlational analysis and logistic regression were completed to identify factors associated with bleeding. RESULTS: A total of 114 adults were included in the analysis. The median length of stay (LOS) was 6.2 (interquartile range = 3.8-11.9) days and bleeding events occurred in a total of 17 patients (15%). A weak correlation was identified for higher cumulative apixaban exposure, increased number of HD sessions while receiving apixaban, and increased hospital LOS ( P < 0.05; correlation coefficient < 0.40). When controlling for confounders, logistic regression revealed that composite bleeding events were independently increased by continuation of outpatient apixaban (odds ratio = 13.07; 95% CI = 1.54-110.54; P = 0.018), increased total daily dose of apixaban (odds ratio = 1.72; 95% CI = 1.20 to 2.48; P = 0.003), and total HD sessions while receiving apixaban (odds ratio = 2.04; 95% CI = 1.06-3.92; P = 0.033). CONCLUSION: The association between these factors and increased bleeding should prompt concern for long-term anticoagulation with apixaban in patients with ESRD receiving chronic HD.