Post on 02-Aug-2020
LongActingInjectables&
Intramuscular(IM)Injections
WhatYouNeedToKnowDarrenChapmanRPNClinicalNurseEducatorMcKesson Canada(Otsuka-Lundbeck Alliance)
LearningObjectivesReviewcurrenthypothesis formedication treatment ofschizophreniaandpsychotic disorders
ReviewcurrentLong-Acting InjectableAntipsychoticClinical Recommendations forClinicians.Reviewcurrentavailable LongActingInjectables inCanada
Reviewlandmarkingtechniques forthefiveinjectionsites usedforall IMInjectionsandwhichsites arebestforLAI’s
DiscussandreviewAdministration InformationandTechniques.
Whatifs?
NowthefunbeginsPracticeTimeforInjections
OverviewSchizophreniaDiseaseState
Chronic,severebraindisorderthatisconsideredoneofthemostdisablingoftheseriousmentalillnesses.Associatedwithbothpositiveandnegativesymptoms
• Positivesymptoms: delusions,hallucinations,disorganized thinking,disorganizedbehaviorandcatatonicmovements
• Negativesymptoms: alogia,avolition,affectiveflattening,anhedonia, dysphoricmood,difficultyconcentrating
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TheDopamineHypothesisofSchizophrenia• Thedopamine (DA)hypothesis istheoldestandmostestablishedoftheschizophreniahypotheses. Ithasevolvedfromclinicalobservations, andreceived empirical validationfromantipsychotictreatmentandmoredirecttestingfromimaging studies.Althoughclearlynotsufficienttoexplainthecomplexityofthisdisorder, itoffersadirectrelationship tosymptomsandtotheirtreatment
• AnissaAbi-Dargham;SchizophreniaResearchForum2012
MajorBrainDopaminePathwaysandSchizophrenia
1. Kandel ER et al. Principles of Neural Science. 3rd ed. St. Louis, MO: Elsevier; 1991. 2. Stahl SM. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 2nd ed.
New York, NY: Cambridge University Press; 2000.
Nigrostriatalpathway1,2
Mesolimbicpathway1,2
• Associated with memory and emotional behaviors1
Mesocorticalpathway1,2
• Associated with cognition and motivation
Tuberoinfundibularpathway1,2
• Controls prolactin secretion
• Controls motormovement
• Delusions• Hallucinations • Disorganized speech/
thinking• Disorganized or
catatonic behavior
Positive symptoms
• Alogia• Affective flattening• Avolition
Negative symptoms
Schizophrenia is associated with impaired dopaminergic neurotransmission in the brain
Hypoactivity in mesocortical pathway- Negative symptoms- Impaired learning and memory
Hyperactivity in the mesolimbic pathway-Positive symptoms
Normal dopamine activity in nigrostriatal pathway(involved in movement regulation)
Normal dopamine activity in tuberoinfundibular pathway(involved in prolactin regulation
Stahl SM. Essential Psychopharmacology of antipsychotics and mood stabilizers. 1st ed. Cambridge: Cambridge University Press;2002.
DopamineHypothesisofSchizophrenia
Improvement of positive symptoms
DopamineAntagonismintheMesolimbicPathwayImprovesPositiveSymptoms
Stahl SM. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 2nd ed.New York, NY; 2000.
Mesolimbic Hyperdopaminergic PathwayPresynaptic
neuron
Dopamine
D2 receptor
Postsynaptic neuron
D2 antagonists
DopamineAntagonismintheMesocorticalPathwayMayWorsenNegativeSymptoms
Possible exacerbation of negative symptoms
Dopamine
D2 receptor
D2 antagonist
Presynaptic neuron
Postsynaptic neuron
Mesocortical HypodopaminergicPathway
Stahl SM. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 2nd ed. New York, NY; 2000.
Hypoactivity in mesocorticalpathway- Negative symptoms- Impaired learning and memory
Hyperactivity in the mesolimbic pathway- Positive symptoms
Normal dopamine activity in nigrostriatalpathway
Normal dopamine activity in tuberoinfundibularpathway
Adapted from Stahl SM. Essential Psychopharmacology of antipsychotics and mood stabilizers. 1st ed. Cambridge University Press; 2002.
LikelyMechanismofActionofAripiprazole inSchizophrenia
Causes blockade of dopamine receptors in mesolimbic system: improvement in +ve symptoms
Stimulation of dopamine receptors in the mesocorticalsystem: improvement in -ve symptoms
Little effect on dopamine receptors in the nigrostriatal and tuberoinfundibular system: little effect on motor function and prolactin
LONG-ACTINGINJECTABLEANTIPSYCHOTICSCLINICALRECOMMENDATIONS
IntroducedMay2013intheCanadianJournalofPsychiatry
Developed byaconsortium ofpsychiatrists acrossCanadadiscussingEvidenceofEffectiveness ofLAI.
Twostudies ofExperiences WithandPerceptionsRegardingLong-Acting Injectable AntipsychoticsfromthePatientandPhysician.
TenRecommendation forClinicianswhenofferingLAIasoneofthechoices oftreatment topatientswithapsychoticdisorder.Also6casestudies accompanythese recommendations. Wewillbrieflyfocusontherecommendations.
TenRecommendations
1.ForAllPhasesoftheillness2.InformedPatientDecision3.ClinicalStabilityandPatients’ChangeinOpinionsandAttitudes4.Physicians’KnowledgeandAttitude5.Nonadherence6.InvoluntaryTreatmentDuringAcutePhasePsychosis7.EngagementWithPsychosocialInterventionsandRehabilitation8.OralSupplementationandStablilizaton9.Monitoring10.SpecialSituations
FROMTHECANADIANJOURNALOFPSYCHIATRYVOL58,No5,SUPPLEMENT1MAY2013
LongActingInjectablesAvailableinCanada
Typical(oilbased)• zuclopenthixol (Clopixol)• haloperidal (HaldolLA)• flupenthixol (Fluanxol)• fluphenazine (Modecate)
Atypical(aqueousbased)• RisperdalConsta• InvegaSustenna• AbilifyMaintena
CharacteristicsofSGA-LAIsandFGA-LAI(1of2)
13
PaliperidoneLAI
RisperidoneLAI
AripiprazoleLAI
Fluphenazine Decanoate
Formulation Aqueous-based nanocrystal
Microsphere aqueous-based Lyophilized powder Ester (prodrug) in
sesame oil
Treatment Initiationfrom oral
150 mg Day 1 & 100 mg Day 8;
no oral supplementation
required
25 mg 3 weeks oral antipsychotic supplementation
400mg (160-300 mg special situations)
2 weeks oral antipsychotic
supplementation
Oral antipsychotic supplementation
for 4-6 weeks
Maintenance Dosing
4 weeks 2 weeks 4 weeks 2-4 weeks
Administration
Deltoid & gluteal IM, no Z-track
required
Deltoid & gluteal IM,
no Z-track required
Gluteal , no Z-track required
Gluteal, Z-track required
Based on individual Canadian product monographs.
Characteristics ofSGA-LAIsandanFGA-LAI(2of2)
14Based on individual Canadian product monographs.
PaliperidoneLAI
RisperidoneLAI
AripiprazoleLAI
Fluphenazine Decanoate
Dosage Range(Volume)
50, 75, 100, 150 mg
eq (0.5, 0.75, 1.0, and
1.5 mL)
12.5, 25, 37.5, and 50 mg
(2 mL for all doses)
160, 200, 300, 400 mg (0.8, 1.0,
1.5, 2.0 mL)
Initial: 12.5 mgSubsequent doses
individualized (12.5-100 mg)
KitsNo reconstitution required; pre-filled syringes
Reconstitution required with
supplied diluent
Reconstitution required with
supplied diluent
1 mL ampoules containing 100
mg/mL fluphenazine decanoate
Storage No refrigeration required
Refrigeration required
No refrigeration required
No refrigeration required
Needle Supplied or Recommended
1” 23G (deltoid < 90 kg or 1.5” 22G if >90 kg)
1.5” 22G (gluteal <90 kg or 2” 21G > 90 kg)
standard needle
2” 20G (gluteal) or 1” 21G (deltoid)
wide bore, slim wall special needle
(supplied)
1.5” 21G (gluteal) standard or 2.0” 21G (gluteal) if obese standard
needle
1.5” 21 or 22G (gluteal) or 2” 21G Standard needle
(filter)
SGA: second-generation antipsychotic; FGA: first-generation antipsychotic; LAI: long-acting injectableBased on IMS Data.
Manchanda R, et al. Can J Psychiatry 2013; 58(5 Suppl. 1):5S-13S.
UseofLAIandOralAntipsychoticsAcross Canada
15
Province%oftotalantipsychotic prescriptions
SGALAI FGALAI OralSGA OralFGA
Alberta 1.5 1.1 91.8 5.6
BritishColumbia 1.9 1.1 89.8 7.2
Manitoba 0.7 0.8 88.7 9.8
NewBrunswick 1.8 1.0 89.6 7.6
Newfoundland& Labrador 0.5 2.5 85.6 11.3
NovaScotia 1.5 1.6 84.3 12.6
Ontario 1.4 1.1 89.7 7.7
PrinceEdwardIsland 2.0 0 81.7 16.3
Quebec 1.0 1.1 89.1 8.9
Saskatchewan 1.6 3.5 86.4 8.4
National 1.3 1.1 89.4 8.2
ProperNeedleLength
Whatisthemostcommonlengthandgaugeofneedleusedforglutealinjections
A) 21gauge38mmneedleB) 22gauge32mmneedleC) 23gauge25mmneedleD) 22gauge38mmneedleE) NoneoftheAbove
Whatisthemostcommonlengthandgaugeofneedleusedforglutealinjections:
D)22gauge38mmneedle
MRIScanofDorsoglutealInjection• Thedistancefrom• skintomusclein• thispatient(line• marked1)is42mm
• Aninjectiongiven• witha21gauge38mm• (11/2”)needle• stayedinthefatty• SCtissue
V.O.Chan(2006)• Overall, only32%(n = 16/50)ofpatientshadintramuscularinjections,withthemajorityofinjections(68%,n = 34/50)beingsubcutaneous.Whenanalyzed bygender,56%(n = 14/25)ofmaleshadintramuscular injectionswhile infemales, theefficacyratewassignificantly lower at8%(n = 2/25).
v.o.chan,etal.(2006)Intramuscularinjectionsintothebuttocks:Aretheytrulyintramuscular?
RecommendedNeedleLength
PatientWeight DELTOIDRecommendedNeedle
GLUTEALRecommendedNeedle
≥90kg(≥200lb) 1½inch,22gauge
1½ - 2 inch,22-21gauge
<90kg(<200lb) 1inch,23gauge 1½inch,22gauge
NeedleLength
Needle length
THE IMPORTANCE OF INJECTING INTO MUSCLE
AlwaysUseaNewNeedle
Z-trackInjectionTechnique
InjectionLandmarking
ThereareFiveInjectionsitesthatcanbeusedforallIMInjectionscanyounamethem?ØDeltoid
ØDorsogluteal
ØVentrogluteal
ØVastus Lateralis
ØRectusFemoris
LandMarkingforIMInjections
Whichinjectionsite? Whichinjectionsite?
22G x 1 ½ ” Safety NeedleGray HubPatient weighs ≥200lb (≥90kg
23Gx1”SafetyNeedleBlueHubPatientweighs<200lb(<90kg)
LandMarkingforIMInjections
Whichinjectionsite? Whichinjectionsite?
TheDeltoidInjection
DeltoidDemarcation
Reproduced with permission
Adapted from Kozier et al. Fundamentals of Nursing: Concepts, Process and Practice. 5th ed. Redwood City, CA: Addison-Wesley Publishing Company, Inc (division of Benjamin/Cummings Publishing Company, Inc);
1995 p 1328–1329
Find the scapula. Locate the acromion process located on the scapula and measure 2 to 3 finger widths in the middle of the arm. Inject at a 90 degree angle.
DeltoidDemarcation
• Itissuggested thatthedeltoid site isabettersitethantheglutealmuscle forsmallvolume(2mLorless)rapidonsetinjections because thedeltoid hasthegreatestbloodflowofanymuscleroutinelyusedforIMinjections.
• Injurytothebrachialarteryandradialnerve(iftheinjection isgiventoolow)andlimited volumeofmedication,whichcanbeadministered (0.5–2mLmaximum),arehighlighted asrisksassociatedwiththedeltoid site.
• MalletJ.&BaileyC.(1996)TheRoyalMarsdenNHSTrustManualofClinicalProcedures,5thedn.BlackwellScience,London.• MalletJ.&DoughertyL.(2000)TheRoyalMarsdenManualofClinicalNursingProcedures,5thedn.BlackwellScience,London• COCOMANA.&MURRAYJ.(2008)JournalofPsychiatricandMentalHealthNursing15,424–434Intramuscularinjections:areviewofbest
practiceformentalhealthnurses
TheDorsogluteal Injection
DorsoglutealInjectionThedorsogluteal site iscomposedofthethickgluteal muscles ofthebuttocks.
Thenursepalpates theposteriorsuperior iliacspinethendrawsanimaginary linetothegreatertrochanter ofthefemur.This line islateraltoandparallel tothesciaticnerve.The injectionsite is,thenlateralandsuperiortothis line.
OlderTeaching
Adapted from Kozier et al. Fundamentals of Nursing: Concepts, Process and Practice. 5th ed. Redwood City, CA: Addison-Wesley Publishing Company, Inc (division of Benjamin/Cummings Publishing Company, Inc);
1995 p 1328–1329Reproduced with permission
Dorsolgluteal Injection
• Dividingthebuttocksintofourquadrantsandusingtheupperouterarea isanother landmarkingtechniqueusedforthissite.Probablythemostcommonlandmarkingtechnique fortheDorsolglutealsite
TheVentroglutealInjection
VentroglutealLandmarkingØ HaveyourpatientpalpatetheirAnterior
SuperiorIliacSpine(ASIS).Thenaskifyoucanpalpatethe(ASIS).Usingyourindexfingeroftheoppositehandofthesideyouaregivingtheinjectionpalpate theASISthenspreadthemiddle fingeralongtheboneyridgeoftheIliacCrestasfarasyoucan.CreatingaVbetweenyourindexandmiddlefinger.Yourthumbshouldbepointingtothegroinareaandyourpinkytothe“stinky”
Ø Thepalmorhealofyourhandwillthenfallonthetrochanter.Toconfirmthishavethepatientswayhis/herhipbackandforthwhilebothfeetareplantedfirmlyontheground(ifstanding).Havethepatientlifttheirlegwhilebent(iflyingdown).
AnteriorSuperiorIliacSpine
MusclesoftheVentroglutealInjection
TheVastusLateralisInjection
VastusLateralisLandmarkingInanadulttheVastusLateraliscan
belocatedbymeasuring ahand’sbreadth laterallydownfromthegreatertrochanterandahand’sbreadthupfromtheknee,identifying themiddle thirdofthequadricepsmuscleasthe injectionsite.TheRectusFemoris isinthemiddle thirdoftheanteriorthigh.
WHATIF• YOUCONTAMINATEANEEDLE• THENEEDLEBECOMESBLOCKED• PTCOMPLAINSOFPAIN,BRUISINGANDLUMPSATTHEINJECTIONSITE
• THEREISBLOODATTHEINJECTIONSITE• YOUDRAWBLOODWHENYOUASPIRATEPRIORTOINJECTION
• APATIENTISGOINGONVACATIONOUTOFPROVINCEORCOUNTRY
PRACTICETIME
•NOWISTHETIMETOPRACTICELANDMARKINGANDGIVINGANIM
INJECTION•WEWILLNEED3-4VOLUNTEERSTO
HELPBYBEINGORPRACTICEMODELS
• THANKYOU
• DARRENCHAPMANRPN• CLINICALNURSEEDUCATOR
• MCKESSONCANADA• darren.chapman@mckesson.ca
• 403-473-7147