Clinical Pearls

The following pearls were selected by the CPNP Program Committee after evaluating a number of member and non-member submissions.

4:15-4:30 PM: Twice a day dosing of Aripiprazole, et al.
Allen Ayala, Pharm.D., BCPP

A drug use evaluation was recently accomplished on Aripiprazole and its use in adjunctive treatment in depressed patients receiving multiple tablets daily. Data collected from 42 military veterans taking Aripiprazole showed 13 of those patients had it dosed two and three times a day, 22 were taking multiple 2-mg tablets, and 18 taking doses less than 5-mg daily for an average duration of 11 months. The manufacturer’s clinical trial submission application for adjunctive use in the treatment of depression used an average daily dose of 10-mg daily in both 6-week trials. The observed dosing regimen of Aripiprazole with this cohort of patients clearly differs with respect to the package insert.

An extensive Medline search, information from the manufacturer’s package insert, and clinical trial evidence affirms decisions based on evidence based medicine. The importance of medication adherence was also addressed with once a day dosing in parallel with a cost containment strategy.

4:30-4:45 PM: Central Anticholinergic Syndrome
Jacquelyn E. Canning, Pharm.D.

Anticholinergic side effects frequently occur as a result of many commonly prescribed medications. When unrecognized, these side effects can cause detrimental medical complications that can cloud the patient’s original presentation. This case will review a patient who experienced severe anticholinergic side effects due to a constellation of medications. The case discussion will review the importance of anticholinergic side effect recognition as well as the role of a pharmacist on multidisciplinary teams.

4:45-5:00 PM: Clozapine-induced Myocarditis
Lindsey H. Kennedy, PharmD, BCPS, BCPP

With the increased recognition and reports of clozapine-induced myocarditis, a need for consistent monitoring of clozapine-related cardiotoxicity has been identified. Utilizing data available in the published literature, an informal monitoring protocol was developed and incorporated into an acute care psychiatric hospital setting. Subsequently, several cases of myocarditis were diagnosed, furthering the need for additional development of a formal monitoring process via computerized physician order entry. This clinical pearl session highlights the progression from casual recommendation to an official protocol that is user friendly and accurate.

5:00-5:15 PM: Levamisole-Induced Vasculitis with Necrosis in Cocaine Users
Niccole Winistoerfer, PharmD, BCPS

Intravenous cocaine use continues to be a widespread problem, inherent with its own set of issues. This case study will address a new issue to be considered when treating chronic cocaine users. Levamisole-laced cocaine is becoming more commonly available, and poses a variety of new threats to cocaine users. In this case, a patient presented with vasculitis and associated necrosis on several occasions to the emergency department of a VA hospital. This case discussion will highlight the importance of proper diagnosis and treatment of not only the patient’s underlying psychiatric and abuse issues, but also the vasculitis with necrosis and possible infection.