Psychiatry 2008 - September 2008 - (Page 41)

common factors associated with relapse in general, any improvements in reducing painful or problematic side effects are desirable. Risperidone long-acting is a water-based injection and may be better tolerated.2 Two recent studies support the use of the deltoid muscle as an alternative injection site for risperidone longacting. In a large (170 patients) multicenter, open-label, single-dose, two-way, cross-over study, Thyssen, et al.,3 studied the bioequivalence of risperidone long-acting injection administered into the deltoid versus gluteal muscle. In this study, no patient withdrew due to injection-site tolerability issues. Overall, 64 percent of patients experienced approximately one adverse event of swelling or redness (48% for gluteal injection and 49% for deltoid injection). However, of these reports, there were no nodule formations. Investigator-rated injection site reactions up to Day 15 revealed no difficulties at the injection sites. For the majority of patients, postadministration ratings of injection site pain by patients indicated minimal or no changes from 2 to 24 hours following injection. In a similarly focused study, Ning, et al.,4 reported the safety and tolerability of risperidone long-acting injection administered into the deltoid. This was an eight-week, multicenter, open-label, multidose study with 53 patients who required higher doses and who previously received risperidone long-acting gluteal injections. Patients received risperidone long-acting injection 37.5mg or 50mg every two weeks into the deltoid muscle. Doses were adjusted based on clinical need. Authors determined that both sites were safe and tolerable for risperidone long-acting injections. This study4 had an 83-percent completion rate. No patients withdrew due to injection site tolerability issues. Investigator-rated mild injection site reactions were observed in 19 percent of patients after injection, but returned to normal prior to the next injection. Patients receiving the higher dose of medication reported higher pain than those receiving the lower dose. It is important to note that there was no evidence of nodule formation at the injection site. Overall, Thyssen, et al.,3 and Ning, et al.,4 determined that risperidone long-acting injection was safe and well tolerated when administered as a single gluteal injection or as a single deltoid injection or multiple deltoid injections. This could be beneficial to patients who do not allow injections to be given at places other than the deltoid, due to paranoia or other psychiatric symptomatology. outpatient setting for the vast majority of his illness. Mr. X’s last hospitalization, which lasted only a few days, was in 1987. Mr. X received an adequate trial of several antipsychotics and mood stabilizers but was nonadherent and showed a definitive lack of improvement. He was given adequate trials of haloperidol, fluphenazine decanoate, thiothixene, and chlorpromazine. Combination therapies included haloperidol decanoate with lithium and valproate; lithium, carbamazapine, and fluphenazine; risperidone, halperidoldol, and valproate; risperidone long-acting injection was safe and well tolerated when administered as a single gluteal injection, as a single deltoid injection, or as multiple deltoid injections. This could be beneficial to patients who do not allow injections to be given at places other than the deltoid, due to paranoia or other psychiatric symptomatology. CASE REPORT Mr. X, a 58-year-old, single, African-American man had been diagnosed with paranoid schizophrenia since 1973. He had a long history of multiple psychiatric hospitalizations and had been treatment refractory. The patient gave written informed consent to be interviewed for this publication. (The internal review board [IRB] of record was contacted prior to submission of this case report. A determination was obtained from that IRB that they do not consider case reports to be human research). As a child, Mr. X was known to be a shy, introverted, nonassertive child with minimal social interactions with a comprehensive history of polysubstance and alcohol abuse. His first recorded psychotic episode was in 1973 when he was 23 years old. He fractured his leg after jumping from the second story of a building in response to his delusions. In 1985, he was arrested for breaking and entering, was found incompetent to stand trial, and the charges were dropped. He had been treated in an olanzapine with valproate and thiothixene; and aripiprazole, valproate and haloperidol. Mr. X was either on haloperidol decanoate or fluphenazine decanoate at the maximum tolerated doses. He received fluphenazine decanoate from 1974 through 1980 and 1985 through 1987. From 1993 through 2007 he received haloperidol decanoate injections. He was given a trial of clozapine at 100mg but he developed excessive drowsiness and was nonadherent with the regular white blood cell (WBC) monitoring. This patient’s most persistent symptoms included paranoid delusions, grandiose ideation, blunted affect, inappropriate laughter and speech, preoccupation with self, irritability, loud verbal outbursts with obscenities, asocial behaviors, aggressiveness, impulsiveness, derailment, rarely assaultive behavior, and no insight into his illness. Mr. X had not had active homicidal or suicidal ideation. The presence of these symptoms after adequate trials with antipsychotics conforms to the definition for treatment refractory schizophrenia.5 [SEPTEMBER] Psychiatry 2008 41

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Psychiatry 2008 - September 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Letters to the Editor Use of Benzodiazepines in the Treatment of Anxiety Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder Risperidone Long-acting Injections: Successful Alternative Deltoid Muscle Injections for Refractory Schizophrenia Alcohol/Substance Misuse and Treatment Nonadherence: Fatal Attraction Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting Journal Watch Classified Advertising Information for Authors

Psychiatry 2008 - September 2008

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