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