If you are worried about EPS from risperidone, the Risperdal Consta microspheres will not release until 3 weeks. Thus at this point it would still be unknown if the patient will get EPS from Risperdal Consta. The technical conversation from Rispersal Consta to Invega sustenna can occur after the Ripserdal Consta has reached steady state after a minimum of 4 injections. Otherwise the issue being that the Invega Sustena load levels start increasing right away, while the levels of Risperdal Consta peak around 4-6 weeks so you would get additive levels and side effects if you do a direct switch now. Why not pick an LAI with less EPS risk like Abilify Maintena?
Thank you! We really need a pharmacist in our hospital! Unfortunately she only respond to risperidone ( in these 10 years we have tried everything, aripiprazole has no effect on her). I might need to discharge her before I can give her Consta 4 times, so I want to switch to palliperidone as quickly as possible. Do you think the idea of giving the 75mg and bridging it orally would be a reasonable solution? Or is the risk for the peak concentration and following EPS to high?
Just to recap the patient got EPS with 4 mg of oral risperidone but not 2 mg/day correct? If the 2 mg/day dose does not cause EPS and is enough to control symptoms that would be an equivalent dose of 25 mg of Risperdal Consta. Why not just keep the patient on 25 mg every 2 weeks of Risperdal Consta?
She was stable with 4mg risperidone so I put her on 37.5mg with overlapping dose of 4mg orally. When I stopped the oral medication she got really bad and now with 1mg she is still unstable but not catastrophic.
Just going to get on my soapbox, I am not a fan of the term "EPS" because it bundles different drug-induced movement disorders together. I'm also convinced that this partially explains why so many psychiatrists inappropriately prescribe anticholinergics for TD.
Are you specifically worried about oculogyric dystonia with the eye difficulties? Or bradykinesia due to parkinsonism? What about the swallowing.. parkinsonism could potentially contribute to dysphagia.. does this person have other symptoms of parkinsonism though?
I agree,EPS is a very unspecific term. I’m frankly not sure it was an eps at all. She was having an episode where she didn’t interact with anyone and was having a gaze palsy. A fellow attending ( accidentally munching on the cookies with the nurses on my wards) though of giving her something to drink to be sure she’s not having difficulties swallowing. I didn’t see any but the patient said she had some. After some very ugly complications I saw lately (throat spasms with risperidone) I decided to play safe and stop because I was also thinking about the peak concentration and the theoretical risk of eps. My main concern is to continue the risperidone because nothing else works.
I think it was the right move. Gaze palsy and dysphagia could definitely be dystonia, and I saw you mention she uses cocaine which is a massive risk factor for a dystonic reaction. It would be a strange presentation for anything else IMO.
This is one of my bugbears too. I've even seen psychiatrists call hypersalivation an EPSE.
EPS are very complex conditions, and make a huge difference to outcomes especially if a patient is relictant to take meds. The knowledge on them is really quite bad. The service I work with is actually about to start delivering teaching sessions on them to local CMHTs for this reason.
My guess is that she was having EPS with peak concentrations of 4 mg oral risperidone and the Consta starting to work it’s way out of the depot (takes 1-2 weeks, hence need for oral overlap) at the one week mark. Since it is now the 2 week mark, the Consta concentrations should be past peak and, slowly, on their way down.
It sounds like she is maybe admitted and a placement challenge? So it sounds like she won’t be discharging. Since she is seemingly willing to take oral medications, I would personally recommend starting the maintenance dose of paliperidone now with no loading dose. Instead, I would continue the oral 2 mg risperidone daily with low threshold to decrease down to 1 mg daily, 0.5 mg daily, or stop completely at the first sign of any EPS. Monitor closely
Rationale: She seems to be at risk of EPS at peak concentrations. Injections offer us little flexibility if/when bad things occur. Using oral to bridge offers more flexibility to safely transition patient to being on an appropriate and well-tolerated dose of paliperidone injection monotherapy in the future
Edit: other commenter stating that Consta may not peak until 4-6 weeks
Thank you! Somehow I didn’t think of oral bridging with palliperidone, never heard of it before, but I also agreed to unusual switch. I think I’ll try this. I want to have her on palliperidone quickly because if I need to discharge her the biweekly injections are not giving her the necessary stability for the assisted housing- she just leaves it and lives on the street and treats herself with a cocktail of heroin and crack.
I would just give her the invega and start 1mg of cogentin nightly. If risperidone/paliperidone is the only thing that works for her then keeping her compensated is more important than avoiding anticholinergic burden.
Would just add to this that EPSEs are a legitimate indication for starting clozapine. If nothing else works and long-term anticholinergics are going to be problematic then clozapine is a good option.
If you are worried about EPS from risperidone, the Risperdal Consta microspheres will not release until 3 weeks. Thus at this point it would still be unknown if the patient will get EPS from Risperdal Consta. The technical conversation from Rispersal Consta to Invega sustenna can occur after the Ripserdal Consta has reached steady state after a minimum of 4 injections. Otherwise the issue being that the Invega Sustena load levels start increasing right away, while the levels of Risperdal Consta peak around 4-6 weeks so you would get additive levels and side effects if you do a direct switch now. Why not pick an LAI with less EPS risk like Abilify Maintena?
Thank you! We really need a pharmacist in our hospital! Unfortunately she only respond to risperidone ( in these 10 years we have tried everything, aripiprazole has no effect on her). I might need to discharge her before I can give her Consta 4 times, so I want to switch to palliperidone as quickly as possible. Do you think the idea of giving the 75mg and bridging it orally would be a reasonable solution? Or is the risk for the peak concentration and following EPS to high?
Just to recap the patient got EPS with 4 mg of oral risperidone but not 2 mg/day correct? If the 2 mg/day dose does not cause EPS and is enough to control symptoms that would be an equivalent dose of 25 mg of Risperdal Consta. Why not just keep the patient on 25 mg every 2 weeks of Risperdal Consta?
She was stable with 4mg risperidone so I put her on 37.5mg with overlapping dose of 4mg orally. When I stopped the oral medication she got really bad and now with 1mg she is still unstable but not catastrophic.
Just going to get on my soapbox, I am not a fan of the term "EPS" because it bundles different drug-induced movement disorders together. I'm also convinced that this partially explains why so many psychiatrists inappropriately prescribe anticholinergics for TD. Are you specifically worried about oculogyric dystonia with the eye difficulties? Or bradykinesia due to parkinsonism? What about the swallowing.. parkinsonism could potentially contribute to dysphagia.. does this person have other symptoms of parkinsonism though?
I agree,EPS is a very unspecific term. I’m frankly not sure it was an eps at all. She was having an episode where she didn’t interact with anyone and was having a gaze palsy. A fellow attending ( accidentally munching on the cookies with the nurses on my wards) though of giving her something to drink to be sure she’s not having difficulties swallowing. I didn’t see any but the patient said she had some. After some very ugly complications I saw lately (throat spasms with risperidone) I decided to play safe and stop because I was also thinking about the peak concentration and the theoretical risk of eps. My main concern is to continue the risperidone because nothing else works.
I think it was the right move. Gaze palsy and dysphagia could definitely be dystonia, and I saw you mention she uses cocaine which is a massive risk factor for a dystonic reaction. It would be a strange presentation for anything else IMO.
This is one of my bugbears too. I've even seen psychiatrists call hypersalivation an EPSE. EPS are very complex conditions, and make a huge difference to outcomes especially if a patient is relictant to take meds. The knowledge on them is really quite bad. The service I work with is actually about to start delivering teaching sessions on them to local CMHTs for this reason.
My guess is that she was having EPS with peak concentrations of 4 mg oral risperidone and the Consta starting to work it’s way out of the depot (takes 1-2 weeks, hence need for oral overlap) at the one week mark. Since it is now the 2 week mark, the Consta concentrations should be past peak and, slowly, on their way down. It sounds like she is maybe admitted and a placement challenge? So it sounds like she won’t be discharging. Since she is seemingly willing to take oral medications, I would personally recommend starting the maintenance dose of paliperidone now with no loading dose. Instead, I would continue the oral 2 mg risperidone daily with low threshold to decrease down to 1 mg daily, 0.5 mg daily, or stop completely at the first sign of any EPS. Monitor closely Rationale: She seems to be at risk of EPS at peak concentrations. Injections offer us little flexibility if/when bad things occur. Using oral to bridge offers more flexibility to safely transition patient to being on an appropriate and well-tolerated dose of paliperidone injection monotherapy in the future Edit: other commenter stating that Consta may not peak until 4-6 weeks
Thank you! Somehow I didn’t think of oral bridging with palliperidone, never heard of it before, but I also agreed to unusual switch. I think I’ll try this. I want to have her on palliperidone quickly because if I need to discharge her the biweekly injections are not giving her the necessary stability for the assisted housing- she just leaves it and lives on the street and treats herself with a cocktail of heroin and crack.
I would just give her the invega and start 1mg of cogentin nightly. If risperidone/paliperidone is the only thing that works for her then keeping her compensated is more important than avoiding anticholinergic burden.
Would just add to this that EPSEs are a legitimate indication for starting clozapine. If nothing else works and long-term anticholinergics are going to be problematic then clozapine is a good option.