New Approaches in Treatment: Medication Innovations and Bypassing First Pass Effect

2. What’s New in the World of Treatment?

3. Objectives: • To Identify novel medication and non-medication approaches, how they purportedly work and their relative success • To be able to transfer knowledge gained from case examples to treatment considerations for similar populations • To be able to offer patients and their families factual information about novel treatment approaches

4. Ketamine

5. Ketamine

6. Newly Released Meds: Vraylar • Cariprazine • Released in 2015 • FDA Approved for treating Manic or Mixed Episodes of Bipolar 1 in Adults • Take once daily

7. Newly Released Meds: Vraylar • Affects Dopamine and Serotonin • Oral Capsules • GoodRx price $1,2000/30

8. Newly Released Meds:Saphris • Asenapine • Released in 2009 • FDA Approved for treating Schizophrenia in Adults and Acute Manic or Mixed Episodes of Bipolar by itself or with Lithium or Valproate in ages 10 and older

9. Bypassing the First Pass Effect

10. Bypassing the First Pass Effect • 20-80% of absorbed med is metabolized in the First Pass Effect! • Two ways to bypass first pass metabolism involve giving the drug by sublingual and buccal routes. The drugs are absorbed by the oral mucosa in both methods.

11. Bypassing the First Pass Effect • In sublingual administration the drug is put under the tongue where it dissolves in salivary secretions. • In buccal administration the drug is placed between the teeth and the mucous membrane of the cheek. Sublingual and buccal methods both avoid destruction by the GI fluids and first pass effect of the liver

12. Newly Released Meds: Saphris • Take twice daily • Affects Dopamine and Serotonin • Sublngual Tablets • GoodRx price $605/30 • In study trials, only 10% of patients stopped the medication due to adverse effects, compared to 6% for placebo

13. Newly Released Meds:Rexulti • Brexpierazole • Released in 2015 • FDA Approved for treating Schizophrenia and as an Adjunctive treatment to antidepressants for Major Depression for Adults

14. Newly Released Meds: Rexulti • Take once daily • Start with dose adjustments at days 4 and 8 • Affects Dopamine and Serotonin • Associated with increased Pathological Gambling and Compulsive Behaviors

15. Newly Released Meds: Rexulti • GoodRx price $1,110/30 • In study trials, only 3% of patients stopped the medication due to adverse effects, compared to 1% for placebo

16. Newly Released Meds:Trintellix • Originally released as Trintellix but name changed to avoid confusion with the blood thinner Brilinta • Vortioxetine • Released in 2013

17. Newly Released Meds:Trintellix • FDA Approved for treating Major Depression for Adults • Take once daily • Affects Serotonin • GoodRx price $351/30

18. Newly Released Meds: Trintellix • GoodRx price $351/30 • In study trials, only 3% of patients stopped the medication due to adverse effects, compared to 1% for placebo

19. Newly Released Meds:Fetzima • Levomilnacipran • Released in 2013 • FDA Approved for treating Major Depression for Adults • Take once daily

20. Newly Released Meds:Fetzima • Start with dose adjustments at day 3 and every 2 days after that based on efficacy and tolerance • Affects Serotonin and Norepinephrine • GoodRx price $365/30

21. Newly Released Meds:Belsomra • Suvorexant • Released in 2014 • FDA Approved for treating Insomnia associated with sleep onset and/or maintenance for Adults • Take before bedtime

22. Newly Released Meds:Belsomra • Affects Orexin Receptors • GoodRx price $338/30

23. Source: NIMH

24. Vagal Nerve Stimulation (VNS)

29. Source: NIMH

31. Source: NIMH

39. How to work with a child psychiatrist- Expectatins eg all children should get an education/be healthy and limits that are genuine eg all children should be free from cancer. Willingness to ehar an overview without interrupting with g=questins that may be logiacallya ddressed- question/by question gives a dis-connected view. Not lead down the bpath of persistnelty asking questions until you get what you are looking for .Leading questions. If questins are genuine about an opinion, go ahead and ask them, but if your ture goal is ”Dr, I want you to tell ____ to _____” then be more direct about it. NeaBeating around the bush ins ineffectuive frustatring and leads to problem of unexpressed agendas, they often go unfulfilleled. If can’t come to a meeting on time at the office, call ahead, other patient s may be seen first, If expectation is to re-do appointment that strated on time when late, either will be turned away or place expectation the clinician will be alter for allt eh aptients in the remainder of the day. Don’t udner-=estimate how long it will take to discuss “just a few minutes of your time” is ususally the sugueae to an hour discussion. Condideratin of all the care being provided prior to the metting as not occurring ina vacuum, WQuestins such as “Have you considered INpt or PHP”? are like asking an educator if they have considered providing special educatin services or and therapist if thye have considered psychotherapy. They’re pretty much automatic consideratins on patient swho are not doing well. More frutful discussin is on what is the best way to help the patient,w hcih include feasiblifty (lack of resource acdcess is main barrier. Resurces incude time, travel transprotatin, paoyment for service, abitlityu to unerstna and follow through insinsturctins. Wrapo aoprund servicdes can help but have their own limitations. Eg case manger who erreminds pt;s of appot;s but does not transport them, usually leads ot not continuing coffice acare. Challelegnes of expectatins/rquests for communication form family/exetneded family/ teachers, case amngers, epical ed providers, princiapals, etc. – al;otte dtime diverted from direct aptient care. Often limited byu rquests for authorization to do something, while being uninformed of resources, tiems spent in ventilation about unchangeable ciremcunstance, eg needs to be better fudning. Fi=time/fudning diversion at the expense of direct patient care, lack of insurance reimbursement or obligtation of the family to apy for discussin sother peopelwant. Privacy/aROI issues. Cartoon of We do not see any evidnecne of, with MD looking through binoculars and picture of illness right behind them.

40. The Case of M.M. M.M. is a 45 year old with childhood-onset Depression M.M. has had numerous failed medication trials and the current medication regimen still only stabilizes M.M. to the point of not being in the hospital, though quality of life is so low M.M. battles suicidal ideation daily

41. The Case of M.M. M.M. is frightened of trying any more medications because of adverse effects experienced over a lifetime

43. The Case of M.M. M.M.’s insurance company sends messages to the pharmacy that they will not fund off-formulary medications without a prior authorization

44. The Case of M.M. M.M.’s insurance company will not prior authorize the medications requested, but does continue to send messages that prior authorization is available and that appeal mechanisms are available

45. The Case of M.M. No appeal overturns the denials of prior authorization

47. The Case of M.M. M.M. has a wealthy relative with a bias against medications The wealthy relative funds TMS, which insurance also does not cover M.M.’s Depression improves until the only provider in the area changes practices and can no longer provide the service

48. Tips for Working with aChild and Adolescent Psychiatrist Time is the most precious commodity

49. Tips for Working with aChild and Adolescent Psychiatrist It won’t take “only a few minutes” if: There is more than one person

50. Tips for Working with aChild and Adolescent Psychiatrist It won’t take “only a few minutes” if: There is more than one subject