Long-acting injectables in practice: What providers need to know

00:00:01 Speaker 1

Good afternoon, everybody. Thank you so much for joining us for our Genoa quarterly webinar today. I'm so excited to have everybody here to talk about our topic of the day, which is long, acting injectables and practice, what providers need to know. So, so honored that you would take time out of your day. I know a lot of you were in community mental health centers, some of you were in hospitals, some of you were in.

00:00:22 Speaker 1

Similar settings and it means a lot that you take the time to learn more about this very important topic today.

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I've got Megan here. That's gonna help me run some poll questions as well as some Q&A here at the end. And we are gonna have a recording of this available for those who may have missed the first section. So you can always share that with your friends after the fact. And we are going to leave some time at the end for some Q&A. So any questions that come up over the course of the presentation, feel free to drop those in the Q&A section.

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Or you can also just put those in the general chat and we'll come to those at the end of the presentation. So without further ado, we'll go ahead and get started.

00:00:56 Speaker 1

So a little bit about me. My name is Blake Shoemaker. I'm a farm DI currently serve as senior manager of pharmacy product here at General Healthcare. What that means currently is I oversee everything related to our long acting injectable program with Genoa. So that means internal policies and procedures that govern what we're able to do as far as administration.

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It also means our internal and external opportunities for growth, and it also means building relationships with our partners to kind of bridge the gaps to LA.

00:01:25 Speaker 1

Care I have worked in a pharmacy since I was 16 years old. So other than bagging groceries for a year when I was 15, pharmacy has pretty much been all I've ever known. Started as a pharmacy cashier all those years ago and I worked my way all the way through the pharmacy to being a pharmacist since 2008. I graduated from Stanford University, just outside of Birmingham.

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Alabama with my farm D in 08 and when I came to Genoa just over five years ago, I was hired as a site manager at the Fort Wood site here in downtown Chattanooga, TN, where I currently.

00:01:56 Speaker 1

We live for the last year and a half or so. I've served as our senior manager of pharmacy product and in that picture you see me holding that little teardrop shape thing. In 2002. I was fortunate enough to win one of our Sages of Clinical Services award for the work that I did a site, part of which had to do with long acting injectables. So it kind of led me here today. So happy to be here.

00:02:17 Speaker 1

With you.

00:02:19 Speaker 1

So to start off with, when we talk about schizophrenia, let's talk about some statistics and some numbers that come to mind. At the top left there you can see that one in 300 people worldwide have schizophrenia. So to compare that to some of the other conditions that you might see in your setting, you look at about one in 500 that have an eating disorder, one in 200 have bipolar disorder.

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So it's similar to bipolar, a little bit more rare.

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Just over one in 100 deal with substance use disorder or self harm. One in 25 deals with depressive disorders. And when we look at mental health diagnosis as a whole, we're talking about one in four people worldwide at the bottom left is a really shocking number, and that's 28 1/2. It's the average potential years of life lost.

00:03:03 Speaker 1

For an individual with schizophrenia, so just think about that for a second. We have a patient that all other things removed. If they didn't have the schizophrenia diagnosis, they would on average live nearly three decades longer than they currently.

00:03:15 Speaker 1

To do that, loss of life can be for many reasons. It can be directly due to the progression of the disease state or it can be comorbid conditions as well because a lot of factors play into that as well. As far as not having stable family situations, stable housing, things like that, that that lead to that loss of life.

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At the top right, 4.9%. That's the percent of people with schizophrenia who die by suicide.

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That is an unbelievably high number and a number that we certainly need to improve upon. If we look at our global suicide rate since 2021, per 100,000 people on the planet, you're looking at about 9 individuals per 100,000. That would lose their life due to suicide if that 100,000.

00:03:56 Speaker 1

If that 100,000 size were all patients who had a schizophrenia diagnosis, you would look at 4900 per 100,000 that lose their life to suicide. Unreal.

00:04:07 Speaker 1

And then the final number is 0.7%. That's the loss of brain matter that we can see after just one psychotic episode that progressively worsens each time thereafter. So the brain matter that is involved in a psychotic episode can be both Gray or white matter and research on the scans that we've looked at over the years indicate that this can be as much as 10CC's of brain.

00:04:29 Speaker 1

Matter per episode. So 10 CCS to kind of give you a visual that's about two teaspoonfuls of brain matter. They can be permanently damaged every time an episode takes place. Your average brain is about 1400 CC's in mass, so it's a loss of about 0.7% per episode.

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Mode and in the areas of the brain where these can be focused in the cortical Gray matter, it can be up to 3% of that mass.

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So on the screen now we have your typical treatment journey. When it comes to schizophrenia, and I know that this diagram has been around for a very long time. Several variations of it are out there, but this is your typical treatment journey from the first symptom.

00:05:05 Speaker 1

Going up to the end point that we're talking about today ending up on a long acting injectable as a therapy of choice. So as we look at this and you kind of familiarize yourself with it, there's a Lancet study that was published in 2021. That study covered 18 years worth of data across all different kinds of study structures. We're talking about randomized controlled trials.

00:05:25 Speaker 1

We're talking about cohort studies, pre post studies that looked at the overall benefit of lais versus the oral equivalent because a lot of the long acting injectable therapies we have do have a direct oral equivalent that can be used when we added up this 18 years worth of data, we're talking about 397,000 patients across 137 different studies.

00:05:46 Speaker 1

So in this huge data set, it overwhelmingly supported the use of lais to improve overall outcomes and reduce hospitalizations as a whole. Now, with it being 137 different studies, we don't have very specific data on the number of hospitalizations, but a recent study that was published in the Annals of General Psychiatry showed that Li treatment as opposed to oral treatment could reduce.

00:06:07 Speaker 1

Hospital readmission rates by as much as 29% compared to an oral medication and for patients who have repeated readmissions, that success rate was 58% for patients who had been frequent Flyers to their local hospitals.

00:06:21 Speaker 1

So as we start down this treatment journey on the slide, your first step is patients present with undiagnosed symptoms. It may be something very obvious, like a psychotic episode, if any, something more subtle, you know, it's not always the same for each patient. But as we look at the median age at which shows undiagnosed symptoms start to present, it's going to be in the 20s to 30s. Now it does show up.

00:06:41 Speaker 1

Earlier in the male population. And then it shows up in the late teens to early 20s on average and in females it shows up in the late 20s to early 30s. But your median is going to be in that 20s to 30s time.

00:06:53 Speaker 1

Change so patient shows up with the symptom and we start treating those symptoms, but we have to rule out other diagnosis while this is going on right? It's not. Obviously we're gonna jump to schizophrenia as a first choice because you can have the overlap of symptoms. So this is where we're gonna put our first poll question.

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Of the day.

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Up and the first question we have for today.

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Is once we.

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Start treating that symptom. What's the average amount of time without treatment for after first presenting with an undiagnosed symptom? Your choice is 6 months, one year, 18 months or two years. And while you put in that information, what am I talking about? So I said overlapping symptoms. What do I mean by that? So.

00:07:36 Speaker 1

When we talk about overlapping symptoms, symptoms can be similar across different diagnosis, right? So some of the symptoms you might see, you have to rule out other disorders. It could be a personality disorder, it could be a mood disorder that has the psychiatric features. It could be delusional.

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Older. So these things aren't exclusive to schizophrenia. You have to rule out these other things. You can also have things like substance induced symptoms that can be common to both or even physical things like a.

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Brain tumor or?

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Certain STD's, like neurosyphilis, can show some psychiatric symptoms that may look like schizophrenia, but it's not actually so. As we return to our poll.

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Question. We look at what the average time without treatment after first presenting with undiagnosed symptoms is the majority of you say that you think that it's about a year. And as we look at the correct answer, you're right. It's actually about a year.

00:08:21 Speaker 1

Uh, average amount of time looking at that 397 patient data set that we're talking about took about a year from the patient showing the initial symptoms starting to treat those symptoms before we actually honed in on the correct diagnosis of schizophrenia, which is depicted there by that red arrow there at the middle. So we have our schizophrenia diagnosis and we know what we're dealing with now. So it's time to get the patient on the correct therapy.

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So the big question and the.

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Big reason we're here today.

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Today is just how much time is this taking on average between getting a diagnosis of schizophrenia to actually being put on their first Li. Now you can see there kind of giving you some information as we get into our second poll question. So the poll question now is based off the 18 years of data that we covered in that Lancet study that I'm talking about, what was the average amount of time?

00:09:06 Speaker 1

Between receiving a schizophrenia diagnosis and actually being put on their first long acting injectable, your choices on this one are going to be one year, 2 years, three years are greater than four years.

00:09:19 Speaker 1

Now as you look at that choice and as you try to make that decision, this path isn't always linear, right? So right here, it says schizophrenia diagnosis, you put them on their first oral antipsychotic. As much as I would love to say, it's as easy as starting a patient on a therapy and a month or two later, you know, it's not right and you need to change it. That road branch is a lot, right. So.

00:09:39 Speaker 1

It may be more realistically you give the patient their first oral therapy, they come back for their follow up a couple months later. You ask how it's going, they say they're still having.

00:09:48 Speaker 1

Systems and you ask them well, are you taking your medication? And they say they googled the side effects when they got home and they didn't like the side effects. So they haven't been taking it like they're supposed to. So it extends that timeline a little bit more, right. They may have to take that medicine a little bit longer before, you know, if it works or not in a more extreme case, maybe the patient doesn't take the medicine, they end up having a more severe episode that lands him in the hospital.

00:10:09 Speaker 1

That takes even longer for you to make that distinction of whether the therapy is sufficient.

00:10:12 Speaker 1

Or not, but you can see on the screen when we looked at that data set on average, patients were treated on four different oral antipsychotic regimens before starting on their first ever Lai. So as we look at our choices here, what do you think the average amount of time was between getting a schizophrenia diagnosis and actually being put on that first Li?

00:10:33 Speaker 1

So the majority here say that they think it's 18 months.

00:10:39 Speaker 1

Actually, no. I'm looking at the wrong answer. Sorry. Most of you here say that you think it's over 4 years. Slightly less say that it's two years than three years than one year. So as we look at the correct answer here and this blew.

00:10:50 Speaker 1

My mind when I read this.

00:10:52 Speaker 1

On average a decade.

00:10:54 Speaker 1

Unbelievable to think that it's taking a decade from a correct diagnosis to getting a patient on a long acting injectable medication that can really improve their quality of life and keep them out of the hospital. So a median age that they're presenting in their 20s and 30s seeking your help, they're not ending up on an Lai on average until they're 38 years.

00:11:14 Speaker 1

Gold.

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And that's why we're here today to do a better job of educating and helping you realize that these aren't the drugs of last resort, that these are options that we need to go to a lot sooner and.

00:11:23 Speaker 1

How we can help you bridge those gaps?

00:11:26 Speaker 1

So I keep throwing this phrase around Lai long acting injectable. You might know what I'm talking about that maybe you're here. You're a member of the office staff. Or maybe you don't know that much about them and you want to learn more. Well, that's why I'm here.

00:11:37 Speaker 1

So what are long acting injectables or lais? Well, Lais are injectable forms of the same therapies that you would choose as an oral option right now for someone with a qualifying diagnosis. These are not just older drugs. That is one of the biggest misconceptions in the field that has kind of hung around to this day because we talked about somebody getting a shot.

00:11:57 Speaker 1

Or a psychiatric condition.

00:11:59 Speaker 1

I love old medical shows and I was huge on the show. ER, I don't know if anybody here was a big ER fan, but I sure was. But you hear, you know, this patient comes in and they're clearly having a psychotic episode. And what does the doctor yell out? Well, I need 10 milligrams of how the all stat. And they give him this shot and it just knocks him out. Cold, right. And that's what we picture. Sometimes when we think about a shot.

00:12:19 Speaker 1

For a psychiatric condition.

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But that's not the case anymore. These are the same drugs with clean side effect profiles for the most part that you would choose.

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As an oral.

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Therapy, just as an injectable form, and I think it's very important that if you don't remember anything else today, remember that everyone needs to be educated on this because a lot of the old knowledge is still out there and we don't need to treat these as drugs of last resort.

00:12:42 Speaker 1

So the main difference between an Lai obviously, besides it being a shot instead of a tablet, is that it removes one of the largest barriers to any therapy and that is non adherence. I don't think I would have to argue with anybody here very much that the hardest part of any prescriber's job, much less somebody who works in the mental health field is trying to make a therapy decision or a therapy.

00:13:03 Speaker 1

Change and trying to decide if you need to make that change based on the medication is not working or the patient's not taking the medication right.

00:13:11 Speaker 1

If the patient gets an injection and we know that medication is on board, we can remove that other item from the table, because if they're showing breakthrough symptoms after receiving an injection, it's not a compliance issue, it's a medication issue and you need to adjust your dose or change therapies. So that's the big benefit here to an L.

00:13:27 Speaker 1

I.

00:13:29 Speaker 1

LAI's depending on when they release use different designs and chemistries.

00:13:32 Speaker 1

To achieve an extended release from the injection site to achieve and maintain effective drug concentrations. So these all achieve that same purpose, but some of them do it a little differently depending on the chemistry. So some are suspended in oil. I know Haldol and Fluphenazine, our older drugs are suspended in oil like sesame oil.

00:13:50 Speaker 1

And when you inject it, it slowly kind of seeps out that base drug into the bloodstream and that's how it releases kind of slowly over time. There are others that are more modern that are crystalline in nature and some of the crystals are really small. And when you inject them, they go right to work and there are others that are larger that take a longer amount of time for the drug to break down before it becomes.

00:14:09 Speaker 1

Active and you still get that same.

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Effect. There are still others that we call depot injections where you may give an injection and you can physically see or feel a knot at the injection site and you can actually physically feel the medication in that area. And as the bloodstream goes by that area, it picks up the medication over time, so they're all releasing those medications over an extended time period that just may be doing it a slightly different way.

00:14:32 Speaker 1

Depending on the chemistry of the medication.

00:14:36 Speaker 1

So I added this slide here. I'm a very visual learner and I know that you may be one of those yourself, so I wanted to kind of show you a little bit of a visual on the kinetics of the medication and what we're talking about when it comes to my eyes. So this very simple graph here will kind of explain that. So your bottom axis on the X axis, we're talking about the amount of time that goes by since you've taken the medication.

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And the Y axis vertically is the concentration of drug in your system.

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And the most important thing is that blue dotted line there in the middle, so that blue dotted line is what we call the minimum effective concentration. So if you're below that line, the concentration is below where you would need to be to be treating the symptom you're looking to treat. If you're over that line, you're at a concentration that is sufficient to treat the symptom you're looking for.

00:15:21 Speaker 1

As far as those symptoms, so to use a very simple.

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For example, let's say I woke up this morning and I.

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Had.

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A headache I'm going to reach for that bottle of ibuprofen. Right. So when I take that ibuprofen to help me with my headache, once I take it, my body is going to start to metabolize that and get it into the system. Concentration is going to rise over time. It's going to get over that line and my headache is going to start to fade, but over time.

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My body is going to start to clear that medication out.

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Until it falls back below that line and then eventually washes out of my system, right? So this amount of time that's over the blue line is the amount of time you're treating the symptom and the before and after is when it's not. So once I drop below this line which the value profen would be like 4 to 6 hours. If my headache comes back I take another dose to push that curve.

00:16:07 Speaker 1

Back over the line, and if it doesn't come back then I just let the drug wash out naturally, right? So that's the simplest explanation of what we're talking about here with drug concentration. So unfortunately with antipsychotics, it's not quite that simple.

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Antipsychotics typically take a longer time to reach what we call steady state. So more accurately, you'll have that first dose that will give you a little concentration and then it will start to wash out of the system. You'll take that second.

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Dose it'll go a little higher?

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3rd dose a little higher 4th dose and so on and so forth.

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Kind of a rough idea here, not an exact.

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Science, but eventually you'll get up here to what we call steady state, where you're staying above that.

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Line at all times.

00:16:48 Speaker 1

Because again, if you're below this line, you're not getting the effective concentration to treat your symptoms and you see how many consecutive doses it takes to get to that line, right? So if a patient starts missing doses, I'll change color of my pin here to kind of depict it. So let's say a patient takes day one, day 2, day three, and then they miss Day 4.

00:17:09 Speaker 1

They're going to fall down here and then day five they take the dose and it's going to take them longer to make it up. The longer amount of time they spend if.

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They miss a dose.

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They're spending time below that line and they're not getting the minimum effective concentration that will treat the condition right. So that's why it's very important that patients take their medications very compliantly to get over and stay above that line so that we're treating those side symptoms right.

00:17:34 Speaker 1

So when we talk about long acting injectables.

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I'll keep the blue. I like the blue. We don't really have a steep curve on a lot of these. It'll steadily rise like this.

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But the difference is, once you reach that concentration and it starts to.

00:17:47 Speaker 1

Get out of.

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The system they're engineered in a way that it's very slowly.

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Eliminated from the system. So you kind of have this plateau effect, but what you notice is that even though you're losing the concentration of the medication, it's always staying over this line.

00:18:02 Speaker 1

That way you're not having the breakthrough symptoms, and if you are having the breakthrough symptoms then you notice the therapy and you need to adjust the dose for.

00:18:09 Speaker 1

You still have to address this section here because you noticed this first amount of time. You're still below the line, so certain lais you may need to add oral supplementation with the base drug to kind of help not down that amount of time that the patient doesn't have symptom treatment or you may have certain LA's where you have a booster dose that you get right out of the gate.

00:18:28 Speaker 1

As a loading dose, and we'll address those a little bit more later on.

00:18:37 Speaker 1

So moving on to our next slide, before I start talking about this, we've got one more poll question to talk about and that's just to learn a little bit more about you, the audience. What is your practice settings, current level of Lai service? So choice A is actively prescribing and administering Li's B is actively prescribing but not administering C is you're interested in setting up a program, but you're not sure how.

00:18:58 Speaker 1

And indeed, you currently don't have an interest in prescribing. Maybe you're here just to learn more as a patient or as an individual. So we'll come back to that in just a minute.

00:19:07 Speaker 1

So some considerations that we talked about with lais and practice, so #1 difficulty with medication adherence, like I said, if we can take adherence off the table because the patient got a shot and we know that medication is on board, we can solve that problem and get to the correct therapy faster. Again, they're not dinosaur drugs. They're current generation medications.

00:19:27 Speaker 1

And we're not having a count on a patient who has a really difficult diagnosis being counted on to take a pill every single day. I know that I don't have a personal complicated diagnosis, but I do get heartburn at night. That's just the point of my life I'm at. I go to bed at night. If I don't take a heartburn pill, I'm going to wake up at about two or three with reflux.

00:19:45 Speaker 1

I'm a pharmacist. I know I need to take that medication. I have all intentions of taking that medication, but sometimes I forget and your normal patient is going to be that person too. So if you have difficulty with medication adherence, either with a patient willingly skipping doses because they don't want to take the medication or they're trying their best and simply can't remember and Li may be a choice for that patient.

00:20:06 Speaker 1

Secondly, current living situation, so I did mention that a lot of these patients do have unstable housing. They may be homeless, they might live in a group home, it might be difficult for them to keep up with the pill bottle if they're out on the streets, they may have that medication lost or stolen. And then you have no medication on board. So if you got a patient with an unstable living situation, that may be a great candidate for an.

00:20:25 Speaker 1

AI.

00:20:27 Speaker 1

You want to ask about your patients experience with injections, so needle phobia is very, very real. You'll have some patients that you'll be able to talk into it simply because they'll be happy. They don't have to take a pill every day, but there are others who are just so freaked out by the idea of getting a needle in their arm or in their gluteal muscle. You know, once a.

00:20:44 Speaker 1

Month or longer?

00:20:45 Speaker 1

That they just they won't do it.

00:20:47 Speaker 1

So you have to carefully evaluate if it's a patient who is OK with being receiving the medication via injection. Transportation options is another one. A lot of our newer LA's have even longer time intervals than one month. Some of them are one month, 2 month, three month, even longer 6.

00:21:04 Speaker 1

Month not having to make his frequent visits to the doctor's office or the pharmacy to pick up a pill bottle patient has transportation issues. They don't have a car or having to rely on public transportation. Might be a good candidate for an LA to cut.

00:21:16 Speaker 1

Down on those number of trips.

00:21:18 Speaker 1

Response to previous therapy options is something else I wanted to call out because a lot of these medications do have oral equivalents.

00:21:26 Speaker 1

And while I say that is because some of them are very obvious. So Abilify, for example, you have Abilify tablets and you have Abilify maintena that is the Lai version of those tablets.

00:21:36 Speaker 1

If a patient didn't respond to oral Abilify, you wouldn't want to put them on an Abilify. Long acting injectable. But we also have an LA I called Aristotle. You may say. Well, let's try on Aristotle, not realizing that the base drug in Aristotle is also aripiprazole, known as Abilify. So be really careful when you evaluate the therapy options that are available.

00:21:56 Speaker 1

That you do pick something that the patient is going to respond to and hasn't failed previously.

00:22:01 Speaker 1

Insurance barriers. Another very real thing to consider. These drugs are very expensive. On average, they can cost thousands of dollars per month. The good news is that a lot of insurance plans Medicaids and Medicare is included, have moved them into preferred status because they do see the benefit of not having to pay for as many hospitalizations and those bad outcomes that normally.

00:22:21 Speaker 1

Happy.

00:22:22 Speaker 1

So they're a lot easier to get now than they were prior. And even if the patient doesn't have great insurance, there are programs out there as far as patient Assistance programs, co-pay assistance that your pharmacy can help you with. Genoa, very happy to kind of share that information with you.

00:22:35 Speaker 1

If you.

00:22:35 Speaker 1

Reach out and then finally frequent utilization of the hospital or ER just going back to you know if patients are ending up in the hospital and it's a compliance issue of not taking those medications.

00:22:46 Speaker 1

Those numbers don't lie as far as reducing the number of hospitalizations for both new patients that are new to diagnosis as well as those who are frequent Flyers to the ER, reducing those by double digits.

00:22:58 Speaker 1

So looking at the.

00:23:00 Speaker 1

Results of the poll, happy to see that 75% of you are actively prescribing administering LAI's 5% are prescribing but not administering. We got about 15% that are interested in setting up a program but not sure how. And I'm happy to talk about that here more in a minute and we have a few that don't have any interest that may just be here to kind of learn more.

00:23:19 Speaker 1

About what Jenna was doing in the space.

00:23:22 Speaker 1

Moving on to that next slide, so let's give a little history of our long acting injectable, because there are plenty of them out there, right. So we had our first generation antipsychotics that came out first and fluphenazine in ante that you see listed there is not used anymore. But I did want to include it because it truly was our first long acting injectable. So for phenazine.

00:23:41 Speaker 1

Gold tablets did go on the market in 1950, been a while ago.

00:23:45 Speaker 1

And it became our first Lai in that enanthate form in the 1960s. Now the fluphenazine deck in O8 or the Fluphenazine deck we call it for short, came out a decade later, in the 1970s, and it's actually much preferred now. It's what we use in all of our pharmacies now because that deck and O 8 Ester form increase the length of action, and we saw way fewer.

00:24:04 Speaker 1

Motor side effects.

00:24:05 Speaker 1

That so that's why you see the deck used and not Internet. The nap date anymore.

00:24:10 Speaker 1

We also have Haldol deck listed in that first generation antipsychotic category, so this day it's still the most commonly used typical antipsychotic. The FDA approved oral heldal back in 1967, but it was introduced as an Li a little bit later in the 1980s.

00:24:27 Speaker 1

Once we got past that point, we get to our second generation antipsychotics, the first of which was Risperdal COM.

00:24:33 Speaker 1

Risperdal oral hit the scene in 1993, but we didn't get that long. Acting injectable form of that until after 2000. It was actually 2003 constant is still available, but it is at every two week interval shot. So we don't see it used as frequently because of that frequent dosing in Vegas. Istebna came after that.

00:24:53 Speaker 1

The oral form of that came on the market in 2006 and we didn't have to wait very long for a long acting injectable there. That one came to market in 2009.

00:25:01 Speaker 1

Now you see, it's a pretzel. Well, Prev listed there. You may or may not have heard of that one. And there's a good reason for that. A land supine oral was approved in 1996, and we eventually got an LOI. That's that's a Press of Rel Prev in 2009, which would have been 13 years later, but it came with a catch. There's actually a REMS program that governs the Press of Rel Prev.

00:25:22 Speaker 1

For those who don't know, REMS RE, EMS is risk evaluation and mitigation.

00:25:29 Speaker 1

Those are drugs that the prescriber and the pharmacy have to register to be able to prescribe and administer those medications. You also have to register your individual patients. The reason for that is there are some, some considerations where you definitely have to have more monitoring requirements to make sure that there are no serious side effects or harm that come to the patient.

00:25:48 Speaker 1

In this case, you actually have to observe the patient for three hours post injection due to a risk of post injection, delirium and sedation syndrome known as PSS.

00:25:57 Speaker 1

Short interestingly enough, PDS does not occur in any other form of the medication. Orally. I am nothing, just the the Li version which is interesting so we don't see a whole lot of Rel Prev just for those REMS considerations, but it is available if you do need it.

00:26:15 Speaker 1

Abilify Maintena was next. It was approved in 2002 as the oral form, but the first Monthly Lai containing that hit the market in 23rd.

00:26:24 Speaker 1

Teen Aristotle, as I said before, also has Abilify in it. It wasn't too far behind Abilify. Maintena Maintena was in 2013. Aristotle was in 2015, but the added benefit with Aristotle was that it had a longer dosing interval. You could do every four weeks, but you could stretch that out to 6 or even 8 weeks for certain doses. As we looked at those extended intervals.

00:26:45 Speaker 1

We've got personas listed there. Perseus was our first monthly risperidone Li that came in about in 2018, but it's actually in the process of going off the market. Nothing is wrong with it. It's just the company has decided to go a different direction and it's not going to be available anymore. But the good news is you SETI is now available as of 2023 to stand in that gap it is also.

00:27:04 Speaker 1

A subq risperidone and it's available for patients who may need to transition, and it's available in both one and two-month dosage forms. The different thing about perusing Musetti is instead of it being intramuscular, it's actually subcutaneous. So you're going to give it just under the surface of the skin as opposed to in the muscle.

00:27:23 Speaker 1

Our next category we have here is our extended interval lais as far as well as some additional categories. I wanted to point to just to kind of educate. So in Vega trends that came to market in 2015, so that's in Vega that lasts 3 months in Vega half year came about in 2021. That's our six month version of the Li which is unreal. To think that we have treatments for schizophrenia.

00:27:44 Speaker 1

Now that they can get two shots a year and be fully treated, so that's incredible. And then Abilify, A simplify came around in 2023. That's a 2 month version of your Abilify Lai.

00:27:55 Speaker 1

We also have Lai categories for substance use disorder as well as HIV. So in Sud you have Vivitrol, there it came about in 2006, that's now texone as the drug. You can see that used for both drug and alcohol abuse. Supplicate and Brixi came about in 2018 and 2023 respectively. That is going.

00:28:14 Speaker 1

To be your injectable.

00:28:15 Speaker 1

Buprenorphine. That's used for STD that those are both REMS medication. So again, it's a a drug that you can prescribe, supplicate and brigati, but both the prescriber and the pharmacy would have to register and you would have to register your patients within that program as well. So just keep that in mind.

00:28:31 Speaker 1

And then our newest category of Lai is going to be your HIV. So we have apparatus kabanova and sun Linka. So Cabina came about first. That's going to be in 2021, that's for active treatment of HIV that can be used once every month or every two months depending on the regimen that the patient's been put on. Aptitude was a year later in 2022.

00:28:52 Speaker 1

That is gonna be our option for injectable.

00:28:54 Speaker 1

Prep. It's given it a 2 month interval after they get a monthly shot for the 1st 2 doses and the really neat thing about aptitude is that it's almost the exact same cost as oral prep that's been on the market for quite some time. So instead of a patient having to take an oral tablet every day or multiple tablets every day, they can get something that's the same price.

00:29:12 Speaker 1

In an injectable form.

00:29:14 Speaker 1

And the newest one of of all is going to be your son Lenka right now it's only indicated for treatment of active HIV, but they are working on getting a prep indication added by the end of this year. And it is a six month version of HIV treatment and hopefully 6 month HIV Prep by the end of 2020.

00:29:32 Speaker 1

Five. And just to pull the curtain back a little bit, we have heard that there is a one year version of this also in the pipeline. So as many options we have available especially for disease states such as STD and HIV, knowing that we're being able to extend that interval is even more exciting down the road.

00:29:49 Speaker 1

So why la ice? I've talked about some of these benefits already, but just to call them out, number one, as always, the medications are always on board. It's gonna be easier to make your therapy decisions or adjustments that lead to better our.

00:30:02 Speaker 1

A 2020 study in the Annals of General Psychiatry looked at 75,000 patients in a 10 year period from 2008 to 2017. When we looked at that 75,000 patients, Lai treatment reduced readmission rate by 29% compared to the same oral medications in those real world settings. Moreover.

00:30:21 Speaker 1

Lais reduced the readmission rate by 58% in patients who have repeated readmissions. So just underscores the importance of using these as opposed to oral therapies.

00:30:31 Speaker 1

#2A reduced cost a reduced cost to the healthcare system, so I know it's a hot button issue right now. We're talking about the economy. We're talking about reducing cost, saving money. You know, what do we keep? What do we eliminate? LA's are a great way to reduce your overall cost medication. Non adherence leads to poorer outcomes and significant economic cost. So if we look at the full picture from 2012 to 2022.

00:30:53 Speaker 1

Looking at spending on behavioral health in that 10 years, it increased 94% overall across all categories. If we look at just inpatient hospital stays, inpatient hospital stays, spending is up 36%, which was $48.6 billion in 2022 alone.

00:31:10 Speaker 1

If we look at 2019 and we just look at schizophrenia, so let's separate everything else out. Let's look at just schizophrenia, those one in 300 that we were talking about.

00:31:19 Speaker 1

For schizophrenia alone, direct healthcare costs due to schizophrenia totaled about $62.3 billion. So direct we're talking about hospitalizations, we're talking about doctor's visits. We're talking about medical.

00:31:31 Speaker 1

All of that kind of stuff. But when we look at indirect cost of schizophrenia, what am I talking about there? We're talking about social programs. We're talking about having to call the police when somebody has an episode. We're talking about having to transport them. We're talk about having to incarcerate them. You know, all of these other hidden costs that aren't directly related to the disease state but are necessary to take care.

00:31:52 Speaker 1

The patient that adds an additional 35 billion on top of the 62.3 billion, so the total burden to the system in 2019 alone was about $100 billion. If you divide that out and you look at relapses where a patient goes back out into the community, they relapse, they end up back in the hospital. The main healthcare cost to the system per relapse was about.

00:32:13 Speaker 1

35,000 per episode, so if you've got a patient who has five relapses over the course of two years, that's adding about $160,000 plus to the system. So certainly something that we can do better.

00:32:25 Speaker 1

And then finally, I know I've said it a million times, but I'll continue to say it, they're current generation medications. They're the same medications that you would pick today as possibly your first choice for an oral therapy. It's just in an injectable form that we can control.

00:32:41 Speaker 1

So if we have all these benefits to lais, why are we not using them? So here are a few things I wanted to call out. Number one, they're specialty medications. Well, what does that mean? That means that you can't always fill a bill at a traditional pharmacy all the time. We hear about patients who have prescriptions for LA. I sent to their local mom and pop pharmacy or their local chain pharmacy.

00:33:02 Speaker 1

They try to fill it and pharmacy gets a rejection that says drug not covered, pharmacy not contracted. And we're not talking rejections where you have to do a prior authorization. It's just that the pharmacy is legally not allowed to build the medication because it's considered a specialty medication and the pharmacy is not a specialty pharmacy. Historically, I know you think Specialty pharmacy, a lot of people think mail order.

00:33:23 Speaker 1

Pharmacy, which can delay the therapy even more so it kind of turns people off to the idea. But what I can tell you.

00:33:29 Speaker 1

Is that Genoa, our general locations are dual licensed, both as long term care and specialty pharmacy. So you're not going to run into that problem with the general pharmacy if you've got one Co located in your clinic or if you're near 1, you send us that prescription, you're not going to get those out of network areas that you would expect at a traditional pharmacy. So you're not.

00:33:47 Speaker 1

Going to run into that issue with us.

00:33:49 Speaker 1

Secondly, prior authorizations.

00:33:52 Speaker 1

Process is a pain. There is no phrase that strikes fear into a medical practice more than prior authorization. We hate them, right? Pharmacies hate them. Doctor's offices hate them. It's a lot of extra paperwork and a lot of extra effort that we just wish we didn't have to do. It's time consuming. It's difficult to navigate, and we've got some tools now that made it a little bit better, like covermymeds.

00:34:12 Speaker 1

Being able to digitize part of the process, but you know it can certainly improve even more and I can tell you that general pharmacies are well equipped to help you with that.

00:34:21 Speaker 1

We do have paperwork on file that you can sign with your local general pharmacy to have US act as your advocate when it comes to the insurance company, and as long as you were able to share the supporting information. So like the diagnosis code that failed therapies, the patient history, stuff like that, we're willing to do those prior authorizations for you so that you can use the therapies and not have to worry about wasting your.

00:34:41 Speaker 1

Time with extra paperwork.

00:34:43 Speaker 1

And then finally, we talk about access issues. The doctor can't access the medications or they don't have the space or the.

00:34:49 Speaker 1

Staff to administer so.

00:34:50 Speaker 1

What am I talking about? Can't access the medications. It's like, well, why can't the patient go to the pharmacy and pick them up, bring them in for their appointment? Well, we actually strongly discourage that, because if a patient picks up the medication and they've got it, we don't know where the patients keeping that medication.

00:35:04 Speaker 1

Between when they pick it up and go into the appointment, did they leave it?

00:35:07 Speaker 1

In a hot car.

00:35:08 Speaker 1

Did they leave it outside? I can't guarantee.

00:35:10 Speaker 1

The.

00:35:11 Speaker 1

The efficacy of that medication because I didn't control it there at the end. Also if a patient has an opportunity to skip an appointment.

00:35:19 Speaker 1

They open that box, they see that there are directions on how to mix it up and administer.

00:35:23 Speaker 1

They might try to administer it to themselves, and I'm not saying they might. They have. We've actually had instances we've heard about in the past. If self administration, where the patient doesn't administer it properly, they end up in the hospital for that reason. So we don't like to hand these off to patients. So that said, how can the doctor access these drugs otherwise? Well, if you're Co located with the general pharmacy, of course we can provide those.

00:35:44 Speaker 1

We can bill those. We can hand them off to the doctor or the nursing staff and they can take it from there. If you don't have a general on site, we can arrange delivery. We can have a technician deliver those to your clinic location.

00:35:55 Speaker 1

If you're far from a general location, we can actually have those shipped to your clinic location so that you can take care of that.

00:36:02 Speaker 1

And it's not a problem of access. We can take care of that for you. In the case of not having the space or the staff to administer if you're a smaller private practice that may not have the full resources to do that. I'm excited to tell you that we are set up for that as well correctly. We have over 90% of our general locations that are able to administer long acting injectables.

00:36:22 Speaker 1

New.

00:36:22 Speaker 1

For patients, some of those requirements can vary state to state. There are some states where we just need to have a a valid prescription and your permission to do it, and that's enough. There are other states where we might have to draw up a legal document, like a collaborative practice agreement, but we're more than willing to help you with that. And not only would we administer the medications we would send you a copy of the consent form, the date of service.

00:36:43 Speaker 1

The lot expiration, all of the drug specific information you would need for your records as well.

00:36:49 Speaker 1

So again, how can your pharmacy team help when it comes to Genoa? Well, your Genoa pharmacy can administer lais in most states. There are a few exceptions to that, one of which is New Jersey. We don't have laws in New Jersey that allow pharmacists to do that yet, but we are advocating to try to see if we can get that changed. DC currently does not allow for that.

00:37:10 Speaker 1

In California doesn't either. But good news in California we are working with the state of California on a new training program that will allow our pharmacists to start doing that. The second-half of this year, so be on the lookout for more details. And if you're in a California location, just reach out to your local general and we'll let you know when we're all set to go.

00:37:27 Speaker 1

On that, secondly, we can provide the delivery of lais. Like I said, if you want to continue to do the administration yourself and you just want us to provide the medications, we're happy to do that. We can deliver them by hand, we can ship them with tracking information. We can do whatever it takes to make sure you're supplied.

00:37:43 Speaker 1

And then finally, like I said, we can help you navigate those state specific requirements that do come up from time to time. You know whether you need a collaborative practice agreement, anything like that, we have our legal team that we work with that will draft the documents and take care of all of that headache for you. Well, all you'll have to do is provide us permission and a signature on the document at the end of the day.

00:38:02 Speaker 1

If you do have questions on your specific state and what we can and can't do, we are going to share some contact information at the end of the presentation to allow you to reach.

00:38:09 Speaker 1

Out to us to find that.

00:38:13 Speaker 1

So opportunities to find success, I wanted to share some success stories because this this isn't just for our new general locations. This is something we can build out in our existing models and I don't think there's any better example of that personally than our meds to meds program that I started here in Chattanooga, TN.

00:38:31 Speaker 1

So when I was a site manager here in Chattanooga.

00:38:34 Speaker 1

Back in 2021, we signed a partnership with the local Regional Medical Center to do a meds to beds program and what that was on the surface was we would provide discharge medications to the patient for the first month post discharge. And instead of the patient getting a prescription and coming to the pharmacy.

00:38:51 Speaker 1

To.

00:38:51 Speaker 1

Pick it up. We would actually prepare the medications, put them in bottles or in compliance.

00:38:55 Speaker 1

Double packs and we would deliver those to the hospital and make sure they were in the patient's hand before they left the hospital to ensure that there were no obstacles to the therapy.

00:39:05 Speaker 1

We often notice that the patient would start a long acting injectable in the hospital setting, but wouldn't continue it once they got into the community and would end up back in the hospital. Now this was a Regional Medical Center and it was a new hospital, so we had patients that came from pretty far distances away for those services, so they weren't retaining my pharmacy as the pharmacy of choice, but I didn't understand.

00:39:25 Speaker 1

Why they wouldn't continue the long acting injectable with their own community pharmacy when they got home?

00:39:31 Speaker 1

Well, what we found was that patients, often the majority of the time, were going to try to get those follow up shots, but they were finding obstacles that were very easily preventable. So they would go to their pharmacy and it would say that they didn't have drug coverage, that covered the medication or it covered the medication, but they needed a prior authorization that the hospital would need to do.

00:39:52 Speaker 1

Or they didn't cover that specific Li, but they would cover a different one.

00:39:56 Speaker 1

All things that would be very easily fixed if the patient were still there with us, but it wasn't being discovered until a month after the patient left hospital. And the big problem was is that they were starting the therapy in the hospital, but think about the hospital setting. We're using the patients medical benefit, right? We're building out hospital stay any of the inpatient meds on the hospital formulary, that's all going to the medical benefit.

00:40:17 Speaker 1

So we're not doing anything to basically validate that the patient has a pharmacy benefit in the 1st place. And if so, what that?

00:40:24 Speaker 1

Members. So we went back to the hospital and we proposed. Hey, it's not as easy as grabbing a sample out of the closet down the hall and by hall means let's use the samples for the patients that really need it. So the patients who don't have any insurance that we need to find a solution for, like maybe a patient assistance program or filling out an assistance form that can get them a grant or something similar.

00:40:44 Speaker 1

Let's use the samples for them, but for the patients that do have the coverage, send us your first prescriptions at Genoa. Let us try to build those out. Let's verify.

00:40:52 Speaker 1

The benefit and then if there is an issue with the drug selection, a prior authorization, a therapy change that's needed.

00:40:58

We'll do it.

00:40:59 Speaker 1

While the patient.

00:40:59 Speaker 1

Is still in the hospital. That way the patient doesn't run into the obstacle a month later, and then your phone is ringing a month after the patient left asking for medical records that you.

00:41:07 Speaker 1

Don't have because you're.

00:41:08 Speaker 1

A hospital and what we found. We initially piloted that approach.

00:41:12 Speaker 1

On a few high risk patients that we're having multiple rehospitalizations and what we found is that those patients were staying out of the hospital. So the hospital made a big change and they eventually decided that they wanted all new start long acting injectable prescriptions to go to our general location.

00:41:28 Speaker 1

And it was really exciting because we were able to remove those obstacles, make sure the patient stayed on therapy. The hospital saw a huge benefit. A lot of these patients were not coming back into the hospital setting, and we provided nearly 300 LAN's in the first year alone to that hospital. And I'm excited to report.

00:41:44 Speaker 1

That that was in.

00:41:45 Speaker 1

2021 and here 4.

00:41:46 Speaker 1

Years later, that hospital still uses that.

00:41:48 Speaker 1

Same Genoa for all new long acting injectable starts.

00:41:53 Speaker 1

Another example are our clinic partner services. So you may have a general location in your clinic and you might have them provide the medications, but you're not interested in having us do your injections because you want that revenue stream. That's totally fine. I don't want anybody to think that we're trying to steal that business from you. You know, you, you can keep that and we'll provide the medication. That's totally fine.

00:42:12 Speaker 1

But just think about in the case of an emergency, like I said, we have over 90% of our sites that are fully approved and set up to administer. So if your clinic one day has an instance where the nurse calls out sick or you have a nurse, that leaves the company and you haven't been able to make another hire to do your injections.

00:42:30 Speaker 1

You know, having to reschedule all those patients or send them to another location. Isn't it great to know that you have a pharmacist there at Genoa that may be able to do this for you. So even though you may not be interested in having us do this for you, normally keep us in mind when it comes to an emergency situation or maybe a pipe patient comes in on the wrong day and your nurse isn't there. Maybe we can help in that situation.

00:42:50 Speaker 1

To make sure the patient gets their medication.

00:42:52 Speaker 1

So we can do that.

00:42:53 Speaker 1

As well. And then finally our surrounding practices example I talked about. So those smaller private practices that would love to use lais, but they don't have the time, the space or the staffing to do. So we're fully equipped to do that for you. And again, if you're interested in that in your state, just send us an e-mail here at the end when we give you the information.

00:43:13 Speaker 1

And we can let.

00:43:14 Speaker 1

You know how to set that up?

00:43:18 Speaker 1

And that's it for the presentation today. As promised, I wanted to leave some time here for some Q&A at the end of the presentation. And we do have some contact information there. If you do have questions on the LOI guidelines in your specific state, you can contact our general clinical services team at clinical services at genoahealthcare.com. If we don't know the answer.

00:43:39 Speaker 1

We can do the research and get it right back to you. So that's how you can share those questions that you don't think of right now, but we will go to the chat and see what questions that we've had come in over the course of the presentation.

00:43:53 Speaker 1

Yeah, we've had people pointing out the the loss of brain matter that 0.7% if a person has 10 relapses, that could be 7% of their brain that's permanently effective. And that's true. The more relapse episodes you have, the more psychiatric episodes you have where you're not sufficiently treating your patient. That's brain loss that you're not going to get back and you're going to reduce the chance of a full recovery. So.

00:44:14 Speaker 1

Just underscores the importance of getting the patient on the correct therapy as quickly as possible, and why lais are the choice.

00:44:25 Speaker 1

I love seeing people give shoutouts to the local Genoa pharmacy. We have one here that's giving a shout out to our Genoa and Granite City, doing all of their long acting injectables. That's great to hear. Good job.

00:44:38 Speaker 1

Is this presentation recorded? Yes. This presentation is going to be available on all of our social media channels after the fact. We'll have that up on our YouTube channel and we have a couple of other channels as well. But YouTube channel, just search for General Healthcare. You'll find our recordings for this presentation as well as many of our others that we've had in the past.

00:44:58 Speaker 1

Oh, good question. Can you let us know what lais leave the not when given. So mainly that's going to be your old generation lais like your Hal dolls and your fluphenazine. Yes, they have that sesame oil component. You can kind of feel it under the surface of the skin, but even more so your newer subcube, risperidone, that's going to be your personas.

00:45:18 Speaker 1

On your uzuki, we're giving those just under the surface of the skin, so it's even easier to see. So the ones there are going to be the more obvious ones. So held off the financing for your older drugs and then your your zetti and personas are going to leave that knot more often than not.

00:45:39 Speaker 1

Rims for Sublocade and Brigati are easier than they look if you have an on site pharmacy then you can operationalize rapid start protocols which is a game changer for OU D that is correct. I know that REMS programs as a whole can be kind of a dirty word because they are difficult to set up sometimes, but they do have fast track programs. If you have a Co located pharmacy where they can kind of help you.

00:46:00 Speaker 1

Expedite the process, especially in a diseased state like OU D That's so important for us to treat.

00:46:10 Speaker 1

Oh, that's a good question. Is Genoa able to service commercially insured patients are just Medicare? We are able to service all plans as long as we are on contract with them. So my old site primarily we did Medicaid, we had some Medicare, you know, Medicaid, Medicare probably made-up 95% of my business, but we didn't have did have some commercial plans that came through as well.

00:46:30 Speaker 1

If you're curious about a specific commercial plan, I would say just call the number on the back of your card for consumer services or for doctors you know, prescriber services, and ask if your local general pharmacy is considered on contract or in network.

00:46:44 Speaker 1

Would be the easiest way to do it.

00:46:49 Speaker 1

Would it be possible for you to send the study you cited early in this presentation, the 18 year study really good question. So I know that the study itself, I think you may have to pay for the file. I know the abstract is available for free if you just Google 2021 Lancet study long acting injectables.

00:47:09 Speaker 1

It should come up in your top results because we've actually shared that abstract before, so that's what I would.

00:47:14 Speaker 1

Say.

00:47:15 Speaker 1

We may also try to include a link to that in the description of the video. When we did the upload.

00:47:24 Speaker 1

How about, ER, hospital, administering lais? Any best practices or evidence of benefit? Good question. As far as evidence of benefit, I would just kind of lean on that study that I mentioned earlier about reducing the.

00:47:37 Speaker 1

You know, reducing readmissions by I think 29% for your newer patients that are on therapy. And then by over 50% for those who are repeat readmissions. So I think the evidence of benefit is pretty clear there. As far as best practices, if you're an ER, hospital, I can't under score enough, sending your first doses to a Genoa pharmacy, lining something up like that.

00:47:57 Speaker 1

Because if you don't.

00:47:59 Speaker 1

You know, of course you can use samples, but what normally happens is if a patient doesn't have insurance that covers it, or you have one of those obstacles that I mentioned earlier, you don't discover it until the patient's been gone for a month. So a month later your phone is ringing, your fax machine is ringing. They're asking you to do a prior authorization, and you don't have the records. I mean, you've sent those records for that patient.

00:48:19 Speaker 1

A long time ago to archives and it's going to be hard to get and in the meantime, the patient is rapidly falling back towards that blue dotted line I showed you earlier and then they can decompensate and end up right back in the hospital. So I would strongly recommend sending your first doses to a general pharmacy so that we can basically identify and remove those obstacles before they even leave.

00:48:40 Speaker 1

What percentage of patients suffer significant ongoing adverse reactions due to the long acting nature of these medications? So that's a good question as well. Normally what you will do before you give a patient, I'll be it long acting injectable, you will give them a trial of the oral form just to make sure that the patient tolerates the medication, OK and doesn't have any kind of an allergic reaction.

00:49:00 Speaker 1

Our severe adverse event, depending on the drug that can vary a little bit in the literature, it can be 7 days, 14 days.

00:49:07 Speaker 1

You know, 10 days in any number, but normally if an adverse event like that is going to show up, it's going to show up during the world trial. It would be incredibly, incredibly rare that an adverse event would show up. You know, the patient does the oral trial. They have no side effect and then they get the Lai and they have the side effect. If it's going to show up, it would show up at a similar rate between the oral and the Lai.

00:49:28 Speaker 1

So if they have an adverse event on the oral trial, you might want to try different Lai.

00:49:38 Speaker 1

Shout out to a general location in Colorado. Happy to hear that.

00:49:44 Speaker 1

Gentlemen Wheaton, shout out to them as well. Perfect.

00:49:49 Speaker 1

Check one other place here.

00:49:55 Speaker 1

Are we anticipating any changes to developing, prescribing or administering lais either due to regulatory or supply chain changes in the near future? Ooh. OK. So without getting too much into the politics, I know that there are talks right now with manufacturing and tariffs and stuff like that correctly. We have not seen any changes to the supply chain.

00:50:16 Speaker 1

A lot of your pharmacies are buying from wholesalers that have warehouses that are just packed full of these LAN's that have a supply on.

00:50:24 Speaker 1

And and we normally get pretty good lead time if there's going to be any kind of an outage. And many of these LI's are not like one off products. So like for example the the example I gave earlier, Abilify, Maintena and Aristotle both have aripiprazole as the base drug. So there are alternatives. You can you can go to.

00:50:44 Speaker 1

If in the unlikely event that one became on back order or unavailable, there are other options. You could switch them to. You know, per series you said. Yeah, I talked about Risperdal constant, another risperidone containing 1. So there's a few there.

00:50:57 Speaker 1

There and then there's any number of in Vegas, you know, one month, three months, six months. So we're not seeing any changes now. We are keeping an eye on it. But there are other backup options available if you need them.

00:51:13 Speaker 1

Oh, OK, good question about my chart that I drew earlier. Why do some lais require oral supplementation or which laids require oral supplementation?

00:51:23 Speaker 1

Or loading doses, so the ones that come to mind immediately. So risperidone, so your Risperdal constant that came out that's the one that comes to mind. Sometimes you have to do as much as 21 days of oral supplementation when you start somebody on Risperdal CONSTA. I know aripiprazole it can be up to 14 days depending on the dosage form so for Abilify.

00:51:44 Speaker 1

Antenna I think the literature says up to 14 days of oral tablet.

00:51:48 Speaker 1

Aristotle A is a little bit different because Aristotle does have what they call the initio dose. So how that works is that they have an immediate release Lai and then you would give the maintenance dose the same day. So you would do the initio in one location and then your maintenance dose in the other location at the same time and it would give basically two peaks that would overlap.

00:52:08 Speaker 1

To kind of cut down on the amount of time that was spent below that minimum effective concentration. So the ones that immediately come to mind are risperidone and aripiprazole. Depending on which one you.

00:52:19 Speaker 1

I know in Vega is a a big one that they do a loading dose. So for in Vegas estena you would do an initial dose and then you would do a follow up dose 4 to 8 days later to kind of maintain that peak and get it where it needs to be. And then you would continue with maintenance after the fact. So the more current generation LA as you don't see nearly as much of the world lead in that you have there.

00:52:45 Speaker 1

All right. Well, I think that's it for the questions. Again, we have our e-mail listed here, clinical services at generalhealthcare.com. Again, I know you have a lot of things you can be doing with your day, patient facing and you know probably watching this on a lunch break or something. But I'm honored to have spent the time with you to let you know a little bit more about LA eyes and how important they are and how we need to do a better job.

00:53:05 Speaker 1

To improve these outcomes for patients.

00:53:07 Speaker 1

Overall, like I said, the emails there. If you think of any questions after the fact, this recording will be available on our YouTube channel and other social media outlets after the fact. Just search General Healthcare on YouTube. We should have that recording up very soon, but again thanks for attending today. I hope everybody has a great rest of the week and thanks for everything you do for us out in the field.