Pharmacology

Clinical Update

PrEP: Introduction to the Basics

Topics: Addiction | Addiction Treatment | HIV | Medical Comorbidities | Medication | Pharmacology | Prevention | Substance Use | Substance use disorders

Great strides have been made in HIV treatment and prevention during the last 2 decades, resulting in falling numbers of new HIV infections during that time span. But since 2013, the rate of new infections has mostly plateaued at just under 40,000 new infections per year (www.hiv.gov). Those at highest risk of infection remain men who have sex with men,

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Expert Q&A

Perioperative Management of Patients on Buprenorphine Maintenance

Topics: Addiction | Addiction Treatment | Buprenorphine | Medical Comorbidities | Medication | Opioid epidemic | Opioid Use Disorder | Opioids | Pain | Pharmacology | Suboxone | Substance Use | Substance use disorders

CATR: Can you tell us about your background? Dr. Acampora: I used to work as a cardiac anesthesiologist. Later, my interest turned to addiction medicine, and I trained in psychiatry and addiction psychiatry. I currently work in a pain clinic where I helped develop a strategy for managing buprenorphine in the perioperative period. CATR: Where does th

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Research Update

Varenicline and Bupropion: Soaring Again With EAGLES?

Topics: Addiction | Addiction Treatment | Bupropion | Chantix | Co-occurring disorders | Dual diagnosis | FDA Warnings | Medication | Pharmacology | Research | Research Update | Side Effects | Smoking Cessation | Smoking Cessation Agents | Substance Use | Substance use disorders | Suicidality | Suicide | Tobacco | Varenicline | Wellbutrin

Review of: Anthenelli RM et al, Lancet 2016;387(10037):2507–2520 Varenicline (Chantix) and bupropion (Zyban and others) are effective treatments for tobacco use disorder, but their use (and sales) took a big hit in 2009 when the FDA slapped both with black box warnings linking them to psychiatric complications, including suicidal ideation. Although

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Research Update

The COMBINE Study: A Core Paper in the Treatment of AUD

Topics: Acamprosate | Addiction | Addiction Treatment | Alcohol | Alcohol Use | Alcohol use disorder | Alcoholism | Medication | Naltrexone | Pharmacology | Psychotherapy | Research | Research Update | Substance Use | Substance use disorders | Therapy during medication appointment | Therapy with Med Management

Review of: Anton RF et al, JAMA 2006;295(17):2003–2017 Conducted from 2001 to 2004 and published in 2006, the COMBINE study was the largest pharmacotherapy study that assessed the treatment of alcohol use disorder (AUD). Although there were significant data on the use of naltrexone and acamprosate (both had been FDA approved), widespread use had no

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News of Note

New Generic Versions of Naloxone

Topics: Addiction | Addiction Treatment | Clinical practice | Medication | Naloxone | News of Note | Opioid epidemic | Opioid Use Disorder | Opioids | Overdose | Pharmacology

Naloxone, a rescue medication effective for reversing opioid overdoses, will soon be available in two generic forms for layperson use. Naloxone nasal spray is the generic version of branded Narcan Nasal, which currently sells for $150 for two doses. The generic version will be much cheaper. Naloxone auto-injector is the generic version of Evzio au

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Research Update

Gabapentin Enacarbil XR Efficacy Less Than Expected for AUD

Topics: Addiction | Addiction Treatment | Alcohol | Alcohol use disorder | Alcoholism | Clinical practice | extended-release | Medication | Novel Medications | Pharmacology | Psychopharmacology | Research Update

Review of: Falk DE et al, Alcohol Clin Exp Res 2019;43(1):158–169 Gabapentin enacarbil extended-release (GE-XR) (Horizant) is an extended-release version of gabapentin. GE-XR is a prodrug, meaning that once ingested it is metabolized into gabapentin. It is currently approved for treatment of postherpetic neuralgia and restless legs syndrome. It di

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Research Update

Can Buprenorphine Improve PTSD Symptoms?

Topics: Addiction | Addiction Treatment | Antidepressants | Buprenorphine | Co-occurring disorders | Comorbidity | Dual diagnosis | Medication | Opioid Use Disorder | Pharmacology | PTSD | Research Update | SSRIs

Review of: Lake EP et al, Am J Addict 2019;28(2):86–91 For many years, the mainstay of treatment for PTSD has been the SSRI class of medications, but many of our patients still suffer crippling symptoms despite optimal antidepressant medication dosing. PTSD is often accompanied by opioid misuse, sometimes in an effort to self-treat the hyperarousal

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Clinical Update

Oxcarbazepine: Close, but no Cigar

Topics: Bipolar Disorder | Carbamazepine | Mania | Mood Stabilizers | Oxcarbazepine | Pharmacology | Psychopharm Myths | Psychopharmacology

You are selecting a mood stabilizer for a 29-year-old woman with mania. If it works, she’ll need to take it long term, but with adherence rates hovering around 50% in this illness, that’s not a likely prospect. The FDA-approved options are not very high on tolerability, but what about oxcarbazepine? Oxcarbazepine (Trileptal) is often used in bipola

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News of Note

Lumateperone and lemborexant

Topics: Antipsychotics | Belsomra | Caplyta | Dayvigo | Hypnotics | Lemborexant | Lumateperone | News of Note | Orexin | Pharmacology | Psychopharmacology | Suvorexant

Two new psychiatric medications were approved in the final days of 2019. One is the first of its kind, an antipsychotic with minimal dopaminergic blockade: lumateperone (Caplyta). The other is lemborexant (Dayvigo), a variation on the hypnotic suvorexant (Belsomra). Lumateperone (Caplyta)Though classified as an atypical antipsychotic, lumateperone is u

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Research Update

Optimal Antidepressant Doses in Major Depression

Topics: Antidepressants | Bupropion | Citalopram | Depression | Depressive Disorder | Escitalopram | Fluoxetine | Mirtazapine | Paroxetine | Pharmacology | Pharmacology Tips | Research | Research Update | Sertraline | SSRIs | Venlafaxine | Wellbutrin

Review of: Furukawa TA et al, Lancet Psychiatry;2019;6(7):601–609 Type of study: Systematic review and meta-analysis Most antidepressants do not have a linear response curve. In other words, the benefits level off as the dose goes up. If the dose gets too high, the side effects start to outweigh those diminishing returns. What’s not clear is whe

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Highlights

Highlight From This Issue

Topics: Bipolar Disorder | Carbamazepine | Mania | Mood Stabilizers | Oxcarbazepine | Pharmacology | Psychopharm Myths | Psychopharmacology

In bipolar disorder, oxcarbazepine is slightly better tolerated than carbamazepine, but less effective. While its medical risks are different, they are by no means safer than carbamazepine’s. Its drug interactions can be a problem as well. On average, higher doses of second-generation antidepressants do not bring greater recoveries in major depress

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Research Update

An Answer for Psychotic Depression

Topics: Antidepressants | Antipsychotics | Deprescribing | Depression | Depressive Disorder | olanzapine | Pharmacology | Pharmacology Tips | Psychosis | Psychotic Depression | Research | Research Update | Tardive dyskinesia

REVIEW OF: Flint AJ et al, JAMA 2019;322(7):622–631 TYPE OF STUDY: Randomized, placebo-controlled trial Psychotic features in depression indicate a more severe form of the disease, with a higher risk of hospitalization and double the rate of disability compared with non-psychotic depression. A combination of an antipsychotic and an antidepressant is

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Research Update

Pharmacology for GAD: Complex Choices

Topics: Cymbalta | Duloxetine | Effexor | Generalized Anxiety Disorder | Lyrica | Pharmacology | Pregabalin | Research | Research Update | SSRIs | Venlafaxine

Review of: Slee A et al, Lancet 2019;393(10173):768–777 Study Type: Network meta-analysis With over 2 dozen choices, how do we pick a medication for generalized anxiety disorder (GAD)? The authors of this network meta-analysis sought to answer this question. Network meta-analysis allows researchers to gauge treatments that haven’t been directly c

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Article

Mirtazapine Augmentation: Running Low on Rocket Fuel

Topics: Antidepressant Augmentation | Antidepressants | Depression | Depressive Disorder | Mirtazapine | Pharmacology | Pharmacology Tips | Psychopharm Myths | Psychopharmacology | Psychopharmacology Tips | SSRIs | Treatment-Resistant Depression | Venlafaxine

Adding mirtazapine (Remeron) to a serotonergic antidepressant is a popular augmentation strategy. When added to venlafaxine, the combo was thought to possess a particularly potent synergy that Stephen Stahl called “California Rocket Fuel.” However, the strategy has failed in a handful of new studies, some of them much larger than the original data.

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Ask The Editor

Is Paxil the Best SSRI for Anxiety?

Topics: Antidepressants | Anxiety | Anxiety Disorder | Generalized Anxiety Disorder | Panic Disorder | Pharmaceutical Industry | Pharmacology | Pharmacology Tips | Practice Tools and Tips | Psychopharm Myths | Psychopharmacology | Psychopharmacology Tips | PTSD | Social Anxiety Disorder | SSRIs

Dear Dr. Aiken: Your review of Paxil’s risks in the May issue failed to mention a benefit that’s unique to this drug. Isn’t it the best SSRI for anxiety? Dr. Aiken: Paroxetine’s (Paxil’s) reputation as the anti-anxiety SSRI got off to a running start. It was first launched for panic disorder in 1996, two years before its approval for depres

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Article

l-Methylfolate for Depression: Costly Mistake or Good Thinking?

Topics: Antidepressants | CAM Treatments | Deplin | Depression | Depressive Disorder | Folate | Folic Acid | l-methylfolate | methylfolate | Natural Medications | Nutrition | Pharmacology | Pharmacology Tips | Psychopharmacology | Psychopharmacology Tips | Treatment-Resistant Depression

Folate (Vitamin B9) has a long track record as a low-cost, low-risk augmentation strategy in depression. It’s also available in a more expensive form, l-methylfolate (Deplin), that promises better results but at a premium price. So, is the cost worth it? Folate pathwaysFolate (the natural form of folic acid) is a B vitamin that’s important in psych

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News of Note

A New Treatment for Bipolar Depression

Topics: Antipsychotics | Atypical Antipsychotics | Bipolar Depression | Bipolar Disorder | Depression | News of Note | Pharmacology | Psychopharmacology

On May 28, 2019, cariprazine (Vraylar) became the fourth atypical antipsychotic to receive FDA approval for bipolar depression. The approval was based on two randomized controlled trials involving 1,051 patients and lasting 6–8 weeks. These studies grouped patients into fixed doses from 0.75–3 mg/day. The sweet spot seems to be 1.5 mg/day, which was

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Article

Esketamine Gets FDA Approval

Topics: Depression | Depressive Disorder | Esketamine | Pharmacology | Treatment-Resistant Depression

On March 5, 2019, the FDA approved esketamine (Spravato) nasal spray as add-on therapy to traditional antidepressant medications for treatment-resistant depression (TRD). In this article, I will describe the events that led to esketamine’s development, review the data submitted to the FDA, and discuss what the future might hold for esketamine. Backgr

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Article Links

Risk Evaluation and Mitigation Strategy (REMS) Programs

Topics: Depression | Depressive Disorder | Esketamine | Pharmacology | Treatment-Resistant Depression

Certain psychiatric treatments require both the healthcare provider and patient to enroll in a Risk Evaluation and Mitigation Strategy (REMS) program before they are administered. Below are links to enroll: Brexanolone (Zulresso) http://www.zulressorems.com/ Buprenorphine-based therapies (Suboxone, Subutex) https://www.samhsa.gov/medication-assi

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Expert Q&A

Medication Side Effects: Nausea, Sweating, and Dry Mouth

Topics: Pharmacology | Pharmacology Tips | Side Effects

TCPR: What’s the best way to manage side effects: lower the dose of the current medication or use an antidote? Dr. Mago: If the patient can stay well on a lower dose, that’s usually my first approach. Most side effects are dose related. TCPR: For the rest of this interview, we’ll assume that lowering the dose or changing the medication was not

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