Introduction:Federal and state policymakers, accreditation organizations, and mental health agencies developed standards for evidence-based use of psychotropic medications among youth in foster care. Despite these efforts, foster youth are vulnerable to psychotropic polypharmacy, high dosing, and low rates of monitoring. This manuscript aimed to (1) analyze state-specific psychotropic oversight programs, and (2) examine specific state approaches and outcomes. Methods:State guidelines, including all 50 United States and Washington, DC, were identified via Google search and a Center for Health Care Strategies, Inc., 2018 technical assistance tool. For each state, authors documented whether guidelines were specific to foster care and whether they included thresholds related to polypharmacy, metabolic monitoring, age-based prescribing, maximum dosages, and any distinctive characteristics. Results:Most states (61%) have published a foster care psychotropic guideline; 9 states (18%) do not have a one, and the authors were unable to locate guidelines for the remaining 11 states (22%). More than one-third of foster care youth (38%) live in states with no psychotropic monitoring requirements. Sixty-three percent (n = 32) of states require a prior authorization (PA) or drug utilization review (DUR) for youth prescribed more than 1 psychotropic. Forty-seven states have age-based prescribing support in place, with PA (n = 28) and DUR (n = 9) being the most common oversight processes. Conclusions:States have a wide range of age restrictions, approaches to PA and DUR, and prioritization of monitoring. Some states lack guidelines entirely. Variability in state psychotropic oversight programs, reporting methods, and data collection contributes to barriers to successful optimization of psychotropic prescribing among youth in foster care.
Polypharmacy, gaps in transitions of care, and inconsistent medication monitoring contribute to inappropriate psychotropic prescribing among youth in foster care. Additionally, foster care psychotropic prescribing regulations are complex and insufficient. Acknowledging these concerns, pharmacists have been identified as essential advocates for youth in foster care given their expertise in medication therapy management, medication reconciliation, patient/caregiver education, and interprofessional collaboration. Specifically, inclusion of board-certified psychiatric pharmacists (BCPPs) on the foster care team could allow for the implementation of best practices, including psychotropic stewardship, collaborative telemedicine services, telemedicine teaching initiatives, comprehensive medication management, and procurement of accurate medical and medication histories, amongst others. It is critical that child welfare administrators, health system administrators, and the foster care team consider inclusion of a BCPP to better support prescribing practices of psychotropic medications among youth in foster care.
Introduction:Clozapine-induced constipation may occur in at least 60% of patients, with first-line options typically involving polyethylene glycol or sennosides. However, there may be adherence barriers to an over-the-counter bowel regimen due to the dosage form, lack of insurance coverage, or lack of benefit. One possible solution to address these adherence barriers may include prescribing a secretagogue laxative. However, there is limited literature supporting the use of secretagogue laxatives in clozapine-associated constipation. A case series is presented in which adherence barriers impeded the use of over-the-counter laxatives, and a secretagogue laxative was implemented to manage clozapine-induced constipation. Case Report:In 4 cases, lubiprostone or linaclotide was initiated, either as monotherapy or in combination with over-the-counter laxatives. Reasons for secretagogue laxative initiation included: (1) reducing a complex over-the-counter laxative regimen, (2) a lack of insurance coverage of over-the-counter laxatives, (3) dissatisfaction with polyethylene glycol's palatability, and (4) cognitive impairment leading to decreased adherence to polyethylene glycol. Discussion:It is important that clozapine-induced constipation is managed adequately to prevent severe consequences of gastrointestinal hypomotility. In addition to timely initiation and titration of constipation pharmacotherapy, adherence should be assessed. When adherence barriers to the use of over-the-counter laxatives are present, the use of a secretagogue laxative may be an option, recognizing there is limited evidence to guide this decision. Conclusion:In these cases, adherence barriers to over-the-counter laxatives were identified. A secretagogue laxative was implemented, well-tolerated, and able to be continued for the duration of follow-up.
Introduction:Manufacturer labeling for haloperidol decanoate recommends an initial dose of 10 to 20 times the daily oral dose; however, significant heterogeneity in dosing practices exists. The purpose of this medication use evaluation was to assess initial haloperidol decanoate dosing in psychiatric inpatients. Methods:An institutional review board-exempt retrospective chart review was conducted using data from University of California Health Data Warehouse (UCHDW) from June 1, 2014, to June 1, 2024. Inpatients diagnosed with schizophrenia or schizoaffective disorder aged 18 years or older receiving an initial dose of haloperidol decanoate were included. Patients on dual antipsychotics or those without oral haloperidol within 24 hours before decanoate administration were excluded. The primary outcome was the proportion of patients receiving 10 to 20 times the oral haloperidol dose as per the manufacturer's package insert. Secondary outcomes included dosing characterization and incidence of extrapyramidal symptoms. Descriptive statistics were employed. Results:A total of 147 eligible patients were included, with a mean age of 49 years; 62% of participants were male. The mean oral dose of haloperidol before decanoate initiation was 20.7 mg, and the mean initial dose of haloperidol decanoate was 178 mg. The primary outcome was observed in 47.6% of patients. Of those who received doses outside of the recommended range, 41.5% received a dose less than 10 times the oral haloperidol dose, while 10.9% received a dose exceeding 20 times the oral dose. Conclusion:Fewer than half of the patients evaluated received an initial dose of haloperidol decanoate as recommended by the manufacturer's labeling. These findings underscore the need to further investigate clinician attitudes, comfort, and knowledge on haloperidol decanoate prescribing.
