Week 3 Discussion Initial Post
Application of Course Knowledge
Discuss how the psychiatric mental health nurse practitioner could assist
the client in the creation of a more viable medication management plan.
There is currently an estimated 1% of the global population suffering from
schizophrenia, and unfortunately, nonadherence to the medications they need is a
very common problem for these patients (Cahaya et al., 2022). According to
current practice guidelines, the disabling symptoms of schizophrenia are best
treated with antipsychotic medications as a long-term maintenance plan, however,
nonadherence increases the risk of relapse, rehospitalization, suicide, violence,
and death (Cahaya et al., 2022). Much effort has been put into studying and
designing interventions to improve the highly prevalent noncompliance problems
of schizophrenics and their necessary antipsychotics. In their sweeping systematic
review of these interventions, researchers analyzed 16 studies which used
interventions that involved family, health professionals (psychiatrists, psychologists
nurses, and pharmacists), SMS texting, and smart electronic reminders and 13 of
the studies showed significant improvements in medication adherence compared to
routine care (Cahaya et al., 2022). Some of the interventions included a STOPS
(Supervised Treatment in Outpatients for Schizophrenia) program in which
participants had a key supervisor who was educated on the nature of their illness,
common misconceptions about treatment, the importance of adherence for success
in treatment, as well as basic skills in how to administer and supervise the
medication (Cahaya et al., 2022). In the Meds-Help study, a pharmacy-based
intervention, included in care were medication education session, reminders, and
notification when the patient fails to fill their medication within 7-10 days of the fill
date (Cahaya et al., 2022). The study used collaborative care with pharmacists and
psychiatrists working together as a team to improve nonadherence (Cahaya et al.,
2022). The LEAN (Lay Health supporters, E-Platform, Award, and integration)
study involved recruitment of lay health supports; an electronic platform with
mobile texting/ SMS for medication reminders, health, education, and monitoring;
the awarding of token gifts for positive behavioral improvement; and integration of
texting with the health system (Cahaya et al., 2022). The use of a smart pill
container or electronic pill dispensing device such as a Med-eMonitor (MM) in the
patient’s home, helps remind patients to take medication, provides warnings in the
case of the wrong medication, records side effects experienced by patients, and
follows up via telephone if the patient does not adhere (Cahaya et al., 2022). In my
personal opinion, the very best intervention for controlling nonadherence in our
schizophrenia patients is simply getting the informed consent to switch them from
oral formulations to the long-acting injectable (LAI) intramuscular depot
formulations of many second generation antipsychotics that have been proven very
effective in the maintenance of schizophrenia symptoms.
, Write a prescription appropriate for the client with evidence support.
Since our case study patient’s psychiatric history shows that the second-generation
antipsychotics Risperidone and Olanzapine have been effective in controlling his
symptoms of schizophrenia, so effective that after his first psychotic break at age
17 he was able to successfully graduate from high school. When he was on the
antipsychotic his daily function and quality of life were greatly increased when
his symptoms were managed. As soon as he aged out of the foster care system
and lost the support that institution offered him, specifically medication
management and transportation, he rapidly declined and has had multiple
psychotic episodes over the next few years. For this reason, it is important that
he remain on an antipsychotic long-term. Tate is currently back on an SGA,
Olanzapine, and doing “okay” but still facing barriers to adherence due mostly to
logistical issues. He has the motivation to take his medications but is unable to
adhere often due to lack of consistent transportation to his appointments. For
this reason, I would like to discontinue his oral olanzapine and start him on the
intramuscular depot formulation of Invega Sustena (paliperidone palmitate) which
is medication approved for maintenance of schizophrenia and last for a month.
Changing to a long-acting injectable (LAI) preparation of antipsychotic could
change Tate’s life by giving him long-term coverage of the medication he
requires for control his disabling schizophrenia symptoms and alleviating the need
for remembering to take him medication every day, which has proven to be a
problem for him in the past. If he tolerates the first month and we see that this
medication is effective for his symptoms, then I will likely transition him further
to the Invega Trinza (a 3- month preparation) and then the Invega Hafyera,
which is the answer to schizophrenia nonadherence issues, and has shown
incredibly good data in the trials measuring efficacy and side effect profile. Every
patient transitioning from oral antipsychotics to Invega Sustena must establish
tolerability to the medication before administering a long-term amount. This is
done easily with an initial injection of Invega Sustena IM 254mg on Day 1 and if
tolerated a second dose on Day 8 of Invega Sustena IM156mg. The third dose
must be administered 5 weeks after their first injection (the timing of the second
is not relevant) and for our patient will be 117mg, which is the recommended
maintenance dose for schizophrenia. The proposed equivalency ratio of olanzapine
oral and Invega IM is
2.22 mg/day of olanzapine equals 1.0 mg/day Invega. There is a seamless dosing
pathway from the first dose, which is easy to follow and will help get Tate to the
stable levels of antipsychotic that he needs to have in order to “get his life back.”
Note: Starting him on this medication will require ordering him for labs: Complete
12hr fasting lipid panel, CBC with differential, CMP, HbA1C, and prolactin, as
paliperidone does carry the side effect of prolactinemia.
Application of Course Knowledge
Discuss how the psychiatric mental health nurse practitioner could assist
the client in the creation of a more viable medication management plan.
There is currently an estimated 1% of the global population suffering from
schizophrenia, and unfortunately, nonadherence to the medications they need is a
very common problem for these patients (Cahaya et al., 2022). According to
current practice guidelines, the disabling symptoms of schizophrenia are best
treated with antipsychotic medications as a long-term maintenance plan, however,
nonadherence increases the risk of relapse, rehospitalization, suicide, violence,
and death (Cahaya et al., 2022). Much effort has been put into studying and
designing interventions to improve the highly prevalent noncompliance problems
of schizophrenics and their necessary antipsychotics. In their sweeping systematic
review of these interventions, researchers analyzed 16 studies which used
interventions that involved family, health professionals (psychiatrists, psychologists
nurses, and pharmacists), SMS texting, and smart electronic reminders and 13 of
the studies showed significant improvements in medication adherence compared to
routine care (Cahaya et al., 2022). Some of the interventions included a STOPS
(Supervised Treatment in Outpatients for Schizophrenia) program in which
participants had a key supervisor who was educated on the nature of their illness,
common misconceptions about treatment, the importance of adherence for success
in treatment, as well as basic skills in how to administer and supervise the
medication (Cahaya et al., 2022). In the Meds-Help study, a pharmacy-based
intervention, included in care were medication education session, reminders, and
notification when the patient fails to fill their medication within 7-10 days of the fill
date (Cahaya et al., 2022). The study used collaborative care with pharmacists and
psychiatrists working together as a team to improve nonadherence (Cahaya et al.,
2022). The LEAN (Lay Health supporters, E-Platform, Award, and integration)
study involved recruitment of lay health supports; an electronic platform with
mobile texting/ SMS for medication reminders, health, education, and monitoring;
the awarding of token gifts for positive behavioral improvement; and integration of
texting with the health system (Cahaya et al., 2022). The use of a smart pill
container or electronic pill dispensing device such as a Med-eMonitor (MM) in the
patient’s home, helps remind patients to take medication, provides warnings in the
case of the wrong medication, records side effects experienced by patients, and
follows up via telephone if the patient does not adhere (Cahaya et al., 2022). In my
personal opinion, the very best intervention for controlling nonadherence in our
schizophrenia patients is simply getting the informed consent to switch them from
oral formulations to the long-acting injectable (LAI) intramuscular depot
formulations of many second generation antipsychotics that have been proven very
effective in the maintenance of schizophrenia symptoms.
, Write a prescription appropriate for the client with evidence support.
Since our case study patient’s psychiatric history shows that the second-generation
antipsychotics Risperidone and Olanzapine have been effective in controlling his
symptoms of schizophrenia, so effective that after his first psychotic break at age
17 he was able to successfully graduate from high school. When he was on the
antipsychotic his daily function and quality of life were greatly increased when
his symptoms were managed. As soon as he aged out of the foster care system
and lost the support that institution offered him, specifically medication
management and transportation, he rapidly declined and has had multiple
psychotic episodes over the next few years. For this reason, it is important that
he remain on an antipsychotic long-term. Tate is currently back on an SGA,
Olanzapine, and doing “okay” but still facing barriers to adherence due mostly to
logistical issues. He has the motivation to take his medications but is unable to
adhere often due to lack of consistent transportation to his appointments. For
this reason, I would like to discontinue his oral olanzapine and start him on the
intramuscular depot formulation of Invega Sustena (paliperidone palmitate) which
is medication approved for maintenance of schizophrenia and last for a month.
Changing to a long-acting injectable (LAI) preparation of antipsychotic could
change Tate’s life by giving him long-term coverage of the medication he
requires for control his disabling schizophrenia symptoms and alleviating the need
for remembering to take him medication every day, which has proven to be a
problem for him in the past. If he tolerates the first month and we see that this
medication is effective for his symptoms, then I will likely transition him further
to the Invega Trinza (a 3- month preparation) and then the Invega Hafyera,
which is the answer to schizophrenia nonadherence issues, and has shown
incredibly good data in the trials measuring efficacy and side effect profile. Every
patient transitioning from oral antipsychotics to Invega Sustena must establish
tolerability to the medication before administering a long-term amount. This is
done easily with an initial injection of Invega Sustena IM 254mg on Day 1 and if
tolerated a second dose on Day 8 of Invega Sustena IM156mg. The third dose
must be administered 5 weeks after their first injection (the timing of the second
is not relevant) and for our patient will be 117mg, which is the recommended
maintenance dose for schizophrenia. The proposed equivalency ratio of olanzapine
oral and Invega IM is
2.22 mg/day of olanzapine equals 1.0 mg/day Invega. There is a seamless dosing
pathway from the first dose, which is easy to follow and will help get Tate to the
stable levels of antipsychotic that he needs to have in order to “get his life back.”
Note: Starting him on this medication will require ordering him for labs: Complete
12hr fasting lipid panel, CBC with differential, CMP, HbA1C, and prolactin, as
paliperidone does carry the side effect of prolactinemia.
