Board-Certified Psychiatric Pharmacists and Their Potential Role in Addressing Behavioral Health Workforce Shortages.

Board-certified psychiatric pharmacists (BCPPs) are doctorate-level, board-certified experts in managing medications for people living with psychiatric disorders, including substance use disorders. BCPPs work as part of an integrated health care team that provides comprehensive medication management focused on optimizing medication-related outcomes and ensuring the safety of the prescribed medications. The authors describe BCPP education and training, settings in which BCPPs practice, and in what roles. Current policies that limit BCPP involvement in behavioral health care and proposed solutions to support the role of BCPPs in addressing behavioral health workforce shortages are discussed.

Lithium therapy in patients on dialysis: A systematic review.

BACKGROUND: Lithium is a first-line pharmacotherapy for the treatment of bipolar disorder, but long-term use is associated with nephrotoxicity. However, as dialysis effectively eliminates lithium, it remains a pharmacotherapeutic option for patients on dialysis. This systematic review seeks to evaluate the dosing, safety, efficacy, and monitoring of lithium in patients receiving dialysis. METHOD: A PubMed database search performed May 5th, 2020, identified 535 article titles. After exclusion criteria were applied, a total of 15 articles were included in this systematic review. RESULTS: In 18 patients receiving dialysis, lithium was primarily used for the treatment of mood disorders. The majority of patients received 300-900 mg lithium carbonate thrice-weekly following dialysis, but several alternative lithium salts and dosing strategies were utilized. The pharmacokinetic properties of lithium in dialysis are not well understood and can be complicated by a serum lithium "rebound effect" following dialysis, due to a two-compartment volume of distribution. Additionally, presence of residual diuresis in some patients may be reason to administer lithium more frequently than thrice-weekly following dialysis. Lithium was shown to be an effective pharmacotherapy in all patients, with many demonstrating rapid improvement after drug initiation. Five patients experienced an adverse event on lithium, but only one patient required lithium discontinuation. CONCLUSION: Lithium may be used in patients on dialysis, with close monitoring of pre-dialysis serum lithium concentrations for at least two weeks after treatment initiation, followed by a lower frequency after stabilization to ensure therapeutic concentrations and reduce toxicity risk.

Never Say Never: Successful Clozapine Rechallenge After Multiple Episodes of Neutropenia.

Clozapine is a second-generation antipsychotic with a superior efficacy for the management of treatment-resistant schizophrenia but underutilized because of potential side effects. A 59-year-old Caucasian male veteran was transferred from the long-term care unit to the acute psychiatry unit because of suicidality. He was noted as having a long-standing history of psychosis with significant referential and paranoid delusions. He had experienced two previous trials of clozapine; although he had significant response in the past, both trials ended in neutropenia and an absolute neutrophil count <500 cells per microliter, despite the second trial also including supplemental "as-needed" doses of pegfilgrastim to manage decline in neutrophil counts. This particular strategy of filgrastim use was determined to be a weakness of the second trial. A PubMed search identified recent literature that discussed preemptive dosing of filgrastim to prevent neutropenia. Thus, a protocol was established to administer 300 µg filgrastim subcutaneously, three times weekly, concurrently with clozapine initiation. This plan was discussed on local and national levels to achieve consensus before its initiation. Using a revised, patient-specific protocol led to successful initiation of clozapine and the ability to maintain the regimen for over 24 months without interruption or any further suicidal ideation.

Characteristics of Drug-Related Podcasts and This Medium's Potential as a Pharmacy Education Tool.

Objective. To analyze the publication frequency and characteristics of drug-related podcasts and describe the role of pharmacists in creating content for this audio-based educational medium. Methods. Podcasts that potentially included drug-related educational information were identified based on four podcast categories that were publicly available as of June 2016. Podcasts were screened by two reviewers to determine whether they contained at least five episodes with drug-related content and a minimum of 10 audio episodes. Metrics related to the podcast, audio episodes, and names of the content authors were collected and a descriptive analysis was conducted. Results. Of the 960 podcasts screened, 125 met the study criteria and were included in the descriptive analysis. These drug-related podcasts produced a median of two episodes per month and each episode lasted an average of 27 minutes. The most common professions represented by podcast hosts and guests were physicians (83.2%), followed by nurses and nurse practitioners (11.2%) and pharmacists (10.4%). Podcast content varied widely, with critical care and emergency medicine being the most common (18.4%), followed by general medicine (14.4%) and complementary and alternative medicine (13.6%). Conclusion. Drug-related podcasts are numerous and easily accessible; however, the quality and accuracy of their content cannot be easily determined as episodes do not consistently cite references. Pharmacists appear to be underrepresented in developing this particular genre of educational content, pharmacy educators should consider producing and disseminating educational material through podcasts for students and practitioners.

Naloxegol: A Review of Clinical Trials and Applications to Practice.

Opioid-induced constipation is a known side effect of long-term opioid therapy and may contribute to increased healthcare utilization. Common laxatives such as polyethylene glycol and bisacodyl are often selected as first-line agents. However, refractory constipation may persist despite the addition of a second agent. In such situations, alternate agents may be considered. The peripherally acting mu-opioid receptor antagonist naloxegol was approved in 2014 for management of opioid-induced constipation in adult patients with chronic noncancer pain. This agent is similar to the mu-opioid antagonist naloxone but selectively blocks opioid receptors in the periphery, thereby preventing constipation while avoiding any worsening of pain scores. Given that the medication undergoes hepatic metabolism, it is important to monitor liver function prior to initiation and assess for other medications, which may increase or decrease the levels of naloxegol, to determine whether adjustment in therapy may be required.

Relationship between mirtazapine dose and incidence of adrenergic side effects: An exploratory analysis.

INTRODUCTION: Mirtazapine is an antidepressant with US Food and Drug Administration approval for management of major depressive disorder. Low doses of mirtazapine are often used for management of insomnia, with higher doses expected to provide more noradrenergic effect, and thus a higher degree of activation. If so, use of higher doses at bedtime may not be advisable and may worsen certain neuropsychiatric symptoms. No studies have been performed to evaluate these outcomes. METHODS: This study consisted of a retrospective review of data submitted to the US Food and Drug Administration's Adverse Event Reporting System from January 1, 1995, to August 1, 2015. Cases that were deemed by study authors to represent activation of the noradrenergic system, and for which other confounders could not be identified, were included in the final analysis. The frequency of each specific adverse event was evaluated based on dose and compared to recent prescribing rates to determine if likelihood of a side effect increased with higher dose. RESULTS: The study identified 308 incidences of anxiety, agitation, delusion, hallucination, hypertension, insomnia, nightmare, or tachycardia. After controlling for frequency of prescribing at a given dose, there was a statistically significant increase in rates of tachycardia which correlated with dose. However, after correction for multiple comparisons, results were no longer significant. DISCUSSION: This study failed to support the hypothesis that mirtazapine is more activating at higher doses and appears to support the safety of increasing dose without increasing risk of noradrenergic side effects. Prospective studies will be necessary to confirm these findings.

An emerging role of cGMP in the treatment of schizophrenia: A review.

Schizophrenia is a progressive psychotic disorder with devastating effects on the broad aspects of human emotion, perception, thought, and psychosocial interactions. Although treatment with antipsychotic drugs, the mainstay in the treatment of schizophrenia, the large number of patients with schizophrenia respond poorly to the pharmacological and, the large number of patients with schizophrenia poorly respond to the pharmacological treatment. Although a variety of novel therapeutics have long been tested, to date, no drugs clinically efficacious for schizophrenia are available. The multiple lines of evidence strongly suggest that the modulation of cyclic guanosine monophosphate (cGMP) is a promising target in promoting the novel therapeutic strategies of schizophrenia beyond the "receptor-dependent" psychopharmacology. cGMP is modulated via regulating its synthesis by N-methyl-d-aspartate receptor (NMDAR) and nitric oxide (NO), which regulate guannylyl cyclase (GC), the enzyme producing cGMP. cGMP is also regulated by phosphodiesterase (PDE), the enzyme hydrolyzing cGMP. In this review, we critically evaluate the therapeutic potential of agents modulating cGMP activity by regulating cGMP synthesis including NMDAR enhancers, NO enhancers, NO inhibitors including minocycline with anti-inflammatory properties and PDE inhibitors in improving the negative, cognitive and positive symptoms of schizophrenia. We also discuss the possible mechanisms by which these agents produce therapeutic effects on schizophrenia including cGMP signaling pathways, oxidative stress, and neuroinflammation.

Donepezil-related intractable hiccups: a case report.

This case report describes a man with intractable hiccups probably caused by donepezil. The patient's symptoms were not responsive to commonly used medications for hiccups, but they were improved and completely relieved upon donepezil dose deescalation and discontinuation. We report two occasions in which the discontinuation of donepezil resulted in hiccup resolution and three occasions in which initiation of donepezil was associated with the onset of hiccups. This report contributes to the growing body of literature that describes an association between centrally acting medications and intractable hiccups.

Rationale for iloperidone in the treatment of posttraumatic stress disorder.

Multiple controlled efficacy studies are available to support the use of psychotropic medications in the treatment of posttraumatic stress disorder symptoms. Iloperidone, a recently approved atypical antipsychotic, has yet to be evaluated in such a manner. This unique agent has the highest affinity of all antipsychotics toward alpha-1 receptors. Antagonism of central nervous system alpha-1 receptors has been implicated in certain aspects of posttraumatic stress disorder, as evidenced by the beneficial role of prazosin in treating nightmares. Additional reduction in hypervigilance may occur through blockade of dopamine receptor D2 and serotonin receptors in the 5-HT2 family. Further investigation of iloperidone is warranted in the treatment of patients with posttraumatic stress disorder due to its unique receptor binding profile.

Exploring the potential effect of polypharmacy on the hematologic profiles of clozapine patients.

INTRODUCTION: Clozapine, an atypical antipsychotic with documented efficacy in the management of treatment-resistant schizophrenia, is associated with the risk of adverse hematological outcomes. Of particular concern are reductions in white blood cells (WBC) and absolute neutrophil counts (ANC). Individuals who display moderate leukopenia (3000/mm(3) > WBC ≥ 2000/mm) upon initiation of clozapine therapy are at increased risk of developing agranulocytosis, defined as an ANC less than 500/mm. Complications of agranulocytosis can be severe and include increased risk of infection and mortality. OBJECTIVES: The primary objective of this study was to examine data on clozapine recipients who experienced adverse drug reactions (ADRs) related to decreases in WBC or ANC and ascertain whether other drugs and/or drug interactions had played a role. The analysis included multiple classes of medications. METHODS: A retrospective chart review was performed of open and closed medical records of all inpatient recipients of clozapine at a state psychiatric center between January 1, 2004 and June 30, 2011. Laboratory records of patients prescribed clozapine were examined for abnormal WBC counts or ANC. A hematological ADR was considered to have occurred if there was a substantial drop in either WBC or ANC or mild or moderate leukopenia or granulocytopenia. Each episode was analyzed for medications that might have contributed to the ADR. Data were collected for all scheduled and STAT medications started at any point during the clozapine patient's hospitalization. The following seven medication groups, based on the Therapeutic Classification System of the American Hospital Formulary System (AHFS), were chosen for analysis because they were consistently used in the majority of the patient population: antihistamines, anti-infectives, autonomic agents, cardiovascular agents, antipsychotics, vitamins, and gastrointestinal agents. Pearson correlation coefficients were calculated to identify associations between the presence of hematological ADRs and medications administered concomitantly with clozapine. RESULTS: The following significant correlation coefficients were found between the use of a class of medications and the occurrence of a hematological ADR: antiinfective agents 0.409 (p < 0.01), gastrointestinal agents 0.329 (p < 0.01), and autonomic agents 0.309 (p < 0.01). In the subset of patients who were prescribed a proton-pump inhibitor or ranitidine concomitantly with clozapine, 24/26 (96%) experienced a hematological ADR. CONCLUSIONS: Autonomic agents, anti-infective agents, and proton pump inhibitors and other gastrointestinal agents were all associated with hematological ADRs when co-prescribed with clozapine. Medications from these classes should be initiated cautiously in patients being treated with clozapine to avoid precipitous drops in ANC or WBC that may increase the risk of agranulocytosis.

Hematologic impact of antibiotic administration on patients taking clozapine.

OBJECTIVE: The purpose of this study was to determine if the drop in white blood cell/absolute neutrophil count for clozapine patients on antibiotics is a normal response to the resolution of infection or if the concurrent administration resulted in an abnormal drop in blood counts and further reduction of white blood cell/absolute neutrophil below baseline prior to infection. DESIGN: This was a retrospective record review of all patients who received clozapine and antibiotics concurrently between June 30, 2010, and June 30, 2011. SETTING: Subjects included inpatients on clozapine therapy at a state psychiatric facility. PARTICIPANTS: This protocol was approved by the Institutional Review Board of record. A total of 42 patients prescribed 93 antibiotic regimens were found to meet all of the above requirements. MEASUREMENTS AND METHODS: Medications were placed into distinct groups based on approved use and mechanism of action. Pearson Correlation Coefficients were utilized and were found to be 0.409 (p<0.01), indicating that a statistically significant relationship existed between the use of systemic antibiotics and alterations in hematologic parameters. RESULTS: Each regimen was classified by specific agent as well as whether the final white blood cell/absolute neutrophil was above or below the baseline established for each patient. CONCLUSION: Antibiotics have been identified as one category of medications that may cause decreased white blood cell/absolute neutrophil counts when combined with clozapine. Our study supports the use of either ciprofloxacin or moxifloxacin as agents that may have less risk of reductions in white blood cell/absolute neutrophil counts than are seen with penicillins, cephalosporins, and other antibiotics that may ultimately require interruption or discontinuation of clozapine therapy.