Adasuve for the Rapid Treatment of Agitation in Schizophrenia

JoAnn Filipov, Mercer University College of Pharmacy

Limited options of antipsychotic drug administration exist in the current standard of care for the acute treatment of agitation. [1] According to the Expert Consensus Guidelines for Treatment of Behavioral Emergencies, speed of onset is key in choosing medication administration route. [2] Since intravenous administration of antipsychotics necessitates established intravenous access, oral and intramuscular administrations are more prominently used. However, oral and intramuscular formulations have a more gradual onset of action, unlike intravenous pharmacokinetics, thus allowing for symptoms to escalate before they begin to resolve. [3] It is reported that patients with an episode of acute agitation often resist intramuscular administration, further escalating the risk of intensifying symptoms. Therefore, there is a need for anti-agitation medications with rapid onset of action and acceptable safety profile that are easy to administer. [4]

Loxapine, an antipsychotic indicated for the treatment of schizophrenia. [5] Loxapine is available as a capsule and intramuscular injection formulations, that have demonstrated efficacy in the treatment of agitation. [6] Due to the unmet need, a new formulation of loxapine, AdasuveÒ, was developed that can be inhaled via Staccato inhalation system. The system is shown to distribute loxapine with intravenous-like pharmacokinetics. [7] Below article summarized the efficacy and safety of Adasuve®. [8]

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A Novel drug, Ingrezza, for the Treatment of Tardive Dyskinesia

JoAnn Filipov, Mercer University College of Pharmacy

Tardive Dyskinesia is an involuntary movement disorder induced by continued exposure to dopamine receptor agents (DBRAs). It is associated with persistent, hindering physical conditions causing significant problems for psychiatric patients. [1] Second-generation (“atypical”) antipsychotics were thought have a decreased risk for tardive dyskinesia compared to first-generation antipsychotics, but current literature indicates the risk may be increased with both generations. [2] For management, the two main methods are: 1) reduce the antipsychotic dose or 2) discontinue the drug. However, literature suggests both may not be the best strategies as they may lead to suboptimal management of the psychiatric illness without resolving tardive dyskinesia. [3]

Vesicular monoamine transporter 2 (VMAT 2) inhibitors (e.g. tetrabenazine) have been used to treat movement-related symptoms of Huntington’s disease. [4] They regulate presynaptic packaging and dopamine release into the synapse. Due to this mechanism of action, it was proposed that VMAT2 inhibitors may be able to counterbalance involuntary movement side effects of antipsychotics. [5] Research sparked to develop valbenazine (Ingrezza Ò). Its exact mechanism of action is unknown; however, it is thought to reversibly inhibit VMAT2. [6] In 2017, the Food and Drug Administration approved valbenazine for the treatment of tardive dyskinesia in adults. Below summarizes the phase 3 trial of valbenazine. [7]

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Presumptive Treatment to Prevent Recurrent Vaginal Infections

Shelby Brigman, Mercer University College of Pharmacy

Bacterial vaginosis (BV) is characterized by vaginal malodor and increased white discharge. It is suggested in Phamacotherapy: a Pathophysiologic Approach that BV increases the risk of acquiring other genital infections such as chlamydia, gonorrhea, and trichomoniasis. Comparatively, vulvovaginal cadidasis (VVC) produces vaginal pruritus, burning, and irritation without malodor or increased discharge and commonly occurs in women with uncontrolled diabetes, debilitation, immunosuppression, or pregnancy.1

The United Kingdom national guideline for the management of recurring BV suggests using suppressive 0.75% metronidazole vaginal gel twice weekly as well as a daily probiotic. However, it is noted that receiving metronidazole has shown an increase in development of VVC.2 In guidelines on the management of vaginal discharge in non-genitourinary medicine settings, it is noted that evidence for other regimens for recurrent BV besides metronidazole gel is lacking. These guidelines also recommend an induction and maintenance treatment for up to six months for recurrent VVC. It is suggested that combined hormonal contraceptives increase the risk for recurrent VVC and switching to an alternative contraceptive method is recommended. The same is noted for recurrent BV and copper-bearing intrauterine devices.3

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