Practitioners who do not prescribe concurrent antipsychotic therapy for at least 3 weeks after starting patients on long- acting risperidone by injection should not anticipate any clinical benefits to be derived from the long-acting risperidone during this initial period, since there will be no appreciable level of the drug in the systemic circulation.
The results of this study were presented to various stake­holders to encourage discussion and implementation of improvement strategies. As a result, an education strategy was implemented within the Fraser Health Authority to facilitate appropriate prescribing of long-acting risperidone by injection. Education sessions for physicians, pharmacists, and nurses were conducted at the acute care sites to highlight the pharmaco- kinetic aspects of long-acting risperidone by injection related to dose escalation strategies and the requirement for overlapping antipsychotic supplementation during initial therapy. Also, a preprinted physician order form was introduced, containing guidance about indications for this drug formulation, criteria for provincial drug coverage, and dosing recommendations; the form also includes a section for ordering antipsychotic overlap supplementation for patients who are starting therapy with long-acting risperidone. This form, which highlights the drug’s complex dosing and pharmacokinetic characteristics, must now be completed for new patients starting therapy with long- acting risperidone before the drug is dispensed at any Fraser Health acute care site.

Long-acting risperidone for injection is considerably more expensive than generic risperidone products for oral adminis­tration and other currently available conventional long-acting antipsychotics for injection, with the 25-mg and 50-mg doses costing about $150 and $300 per injection, respectively (as of summer 2010). Therefore, it is expected to have a significant impact on the drug budget of the Fraser Health Authority. In British Columbia, outpatients require PharmaCare special authority approval if they need the provincial government to cover the costs of long-acting risperidone for injection. The high cost may be a barrier to compliance for psychiatric patients without adequate public or private drug coverage once they are discharged from hospital. During data collection for the current study, it was noted that documentation of Pharma- Care special authority approval for outpatient drug coverage was inconsistent and often missing from patient charts. Specif­ically, special authority approval was documented in the health records for only 51% of patients newly started on long-acting risperidone for injection. For patients who cannot afford the drug, this lack of documentation might lead to treatment interruption after discharge, as extra communication among the receiving psychiatrist, the community pharmacy, and the provincial drug coverage program would be needed before patients could receive the next injection. In the current study, it is possible that special authority approval was arranged by the prescribing physician via telephone, without documentation in the chart, but there was no mechanism for us to capture cases in which this occurred. A standardized method of document­ing special authority approval (i.e., the aforementioned preprinted order), accessible to all individuals involved with patient care, including psychiatrists, nurses, pharmacists, social workers, and case managers, would probably help to facilitate seamless transition from acute care settings to community environments by ensuring that patients do not miss their injections because of cost. tadacip

On average, patients received fewer than 3 injections of long-acting risperidone and stayed in the inpatient psychiatric unit for 30 days after their first injection. These findings corroborate results reported by De la Gandara and others who found that patients in their retrospective study received an average of 2 injections over a mean hospital stay of 25 days. Since appreciable release of long-acting risperidone should not be anticipated any earlier than 3 weeks after the first injection and since steady-state drug levels are not reached until week 6, our findings suggest that the patients in acute care settings were not necessarily stabilized because of the introduction of the risperidone, but rather because they were treated in a structured and supportive care environment with concurrent oral antipsy- chotic therapy. It is likely that the effects of the long-acting risperidone did not begin to appear until just before discharge, if at all. One of the limitations of this study is that it was not designed to follow use of antipsychotic medications or patient outcomes after discharge.

One of the main reasons for the introduction of long- acting risperidone for injection was to improve compliance with medication therapy by simplifying dosing regimens. More specifically, the responsibility for administering a medication is shifted from patients, who would be expected to take one or more oral antipsychotics faithfully on a daily basis, to clinicians, who administer the long-acting formulation every 2 weeks. For that reason, it is expected that patients started on long-acting risperidone by injection would eventually discontinue use of oral antipsychotics. Interestingly, in this study the average number of regularly scheduled antipsychotics was 1.1 before hospital admission and 1.7 at the time of discharge. Thus, the average number of antipsychotics increased after initiation of the long-acting risperidone. This finding can be explained by the fact that most patients did not remain in the hospital long enough for complete tapering of their oral antipsychotics. Stabilization on long-acting risperidone might be expected several weeks after initiation of therapy. Hence, a long-term study in an outpatient setting is required to determine if there is an overall reduction in the total number of antipsychotic medications as a result of therapy with long-acting risperidone by injection.

This study was limited by its retrospective nature, the lack of follow-up with patients after discharge from hospital, and the lack of information about clinical outcomes achieved when therapy with long-acting risperidone was started. However, the purpose of the study was to describe current prescribing patterns at the acute care sites of one health authority and to find ways to improve these patterns. Studies evaluating the clinical efficacy and safety of this drug formulation have been published elsewhere. Future studies with follow-up of patients in community settings after hospital discharge would help to describe prescribing patterns such as dosing changes, tapering of oral antipsychotics, and total duration of therapy with long-acting risperidone. Viagra Soft Tabs

CONCLUSIONS

The results of this study indicate that the current prescribing patterns for long-acting risperidone for injection within the acute care settings of the Fraser Health Authority could be improved to meet current recommendations, which are based on the pharmacokinetics of the drug. Methods to improve prescribing patterns may include multidisciplinary education sessions (for physicians, pharmacists, and nurses) and implementation of a regional preprinted physician order form with dosing guidelines and strategies to ensure seamless care during transition from acute care to community settings. Further study is needed to determine whether these interven­tions will affect the appropriateness of prescribing of this drug in acute care sites.