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Board Bomb Bonus Episode: This Long Acting Injectable (LAI) Question Trips Up Clinicians All the Time · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:08
  This
• 0:09
  is
• 0:09
  a
• 0:09
  bonus
• 0:09
  episode
• 0:10
  called
• 0:10
  Board
• 0:11
  Bombs.
• 0:12
  Back
• 0:12
  by
• 0:13
  popular
• 0:14
  demand.
• 0:15
  I
• 0:15
  know
• 0:15
  you
• 0:15
  all
• 0:16
  love
• 0:16
  these
• 0:16
  and
• 0:16
  that's
• 0:16
  why
• 0:17
  we
• 0:17
  do
• 0:17
  these.
• 0:18
  This
• 0:18
  one's
• 0:18
  a
• 0:18
  good
• 0:18
  one.
• 0:19
  It's
• 0:19
  kind
• 0:19
  of
• 0:19
  dripping
• 0:20
  with
• 0:20
  pearls
• 0:21
  to
• 0:22
  keep
• 0:22
  you
• 0:22
  at
• 0:22
  the
• 0:22
  top
• 0:22
  of
• 0:23
  your
• 0:23
  game.
• 0:24
  So
• 0:25
  you
• 0:25
  have
• 0:25
  a
• 0:25
  patient,
• 0:26
  24
• 0:26
  year
• 0:26
  old
• 0:27
  male
• 0:27
  with
• 0:27
  schizophrenia,
• 0:29
  brought
• 0:29
  to
• 0:29
  your
• 0:29
  clinic
• 0:30
  by
• 0:30
  his
• 0:30
  mother
• 0:31
  after
• 0:31
  his
• 0:31
  third
• 0:32
  psychiatric
• 0:32
  hospitalization
• 0:33
  in
• 0:34
  18
• 0:34
  months.
• 0:35
  Each
• 0:35
  time
• 0:35
  he
• 0:35
  was
• 0:36
  stabilized
• 0:36
  on
• 0:36
  oral
• 0:37
  risperidone,
• 0:38
  4
• 0:38
  milligrams
• 0:38
  a
• 0:39
  day.
• 0:39
  Then
• 0:39
  he
• 0:39
  was
• 0:39
  discharged
• 0:40
  and
• 0:41
  found
• 0:41
  to
• 0:41
  have
• 0:41
  stopped
• 0:42
  taking
• 0:42
  his
• 0:42
  medication
• 0:42
  within
• 0:43
  two
• 0:43
  to
• 0:43
  three
• 0:43
  weeks.
• 0:43
  He
• 0:44
  denies
• 0:44
  non
• 0:44
  adherence,
• 0:45
  but
• 0:45
  his
• 0:45
  mom
• 0:46
  reports
• 0:46
  finding
• 0:47
  hidden
• 0:47
  pills.
• 0:48
  He's
• 0:48
  got
• 0:48
  no
• 0:49
  history
• 0:49
  of
• 0:49
  dystonia
• 0:49
  or
• 0:50
  akasthesia
• 0:50
  or
• 0:51
  allergic
• 0:51
  reactions
• 0:51
  to
• 0:52
  risperidone.
• 0:53
  His
• 0:53
  psychiatrist
• 0:54
  decides
• 0:54
  to
• 0:55
  initiate
• 0:56
  in
• 0:56
  Vega
• 0:57
  Sustena
• 0:58
  the
• 0:58
  long
• 0:59
  acting
• 0:59
  injectable.
• 1:00
  Now,
• 1:01
  which
• 1:01
  of
• 1:01
  the
• 1:01
  following
• 1:02
  is
• 1:02
  the
• 1:02
  most
• 1:02
  accurate
• 1:03
  statement
• 1:04
  regarding
• 1:04
  the
• 1:04
  initiation
• 1:05
  of
• 1:05
  this
• 1:05
  medication?
• 1:07
  Is
• 1:07
  it
• 1:08
  A,
• 1:08
  he
• 1:09
  must
• 1:09
  complete
• 1:09
  a
• 1:10
  minimum
• 1:10
  14
• 1:11
  day
• 1:11
  oral
• 1:12
  INVEGA
• 1:12
  trial
• 1:13
  before
• 1:13
  the
• 1:14
  first
• 1:14
  injection
• 1:15
  can
• 1:15
  be
• 1:15
  given?
• 1:16
  Is
• 1:16
  it
• 1:16
  B,
• 1:17
  he
• 1:17
  requires
• 1:18
  no
• 1:18
  oral
• 1:19
  tolerability
• 1:20
  testing
• 1:20
  because
• 1:20
  Invega
• 1:21
  is
• 1:21
  the
• 1:21
  active
• 1:22
  metabolite
• 1:22
  of
• 1:22
  risperidone
• 1:24
  which
• 1:24
  he
• 1:24
  has
• 1:24
  previously
• 1:25
  tolerated.
• 1:27
  Is
• 1:27
  it
• 1:27
  C,
• 1:28
  the
• 1:28
  first
• 1:28
  two
• 1:29
  injections
• 1:29
  must
• 1:29
  be
• 1:30
  given
• 1:30
  in
• 1:30
  the
• 1:30
  gluteal
• 1:31
  muscle
• 1:31
  to
• 1:31
  ensure
• 1:32
  slow
• 1:32
  sustained
• 1:33
  absorption.
• 1:34
  Is
• 1:34
  it
• 1:35
  D,
• 1:35
  oral
• 1:36
  risperidone
• 1:37
  must
• 1:37
  be
• 1:37
  continued
• 1:38
  for
• 1:38
  21
• 1:38
  days
• 1:39
  after
• 1:39
  the
• 1:39
  first
• 1:39
  injection
• 1:40
  to
• 1:41
  Bridge
• 1:41
  the
• 1:41
  gap
• 1:42
  to
• 1:42
  therapeutic
• 1:43
  levels.
• 1:44
  Or
• 1:44
  is
• 1:45
  it
• 1:45
  E?
• 1:45
  He
• 1:46
  must
• 1:46
  complete
• 1:46
  a
• 1:46
  two
• 1:47
  week
• 1:47
  oral
• 1:48
  invega
• 1:48
  trial
• 1:49
  and
• 1:50
  continue
• 1:50
  oral
• 1:51
  supplementation
• 1:51
  for
• 1:51
  21
• 1:52
  days
• 1:52
  after
• 1:52
  the
• 1:53
  first
• 1:53
  injection.
• 1:54
  Let's
• 1:54
  discuss
• 1:54
  this.
• 1:55
  So
• 1:56
  in
• 1:56
  the
• 1:56
  world
• 1:56
  of
• 1:57
  long
• 1:57
  acting
• 1:57
  injectables,
• 1:58
  a
• 1:58
  lot
• 1:59
  of
• 1:59
  the
• 1:59
  protocols
• 2:00
  can
• 2:00
  seem
• 2:00
  overwhelming.
• 2:01
  And
• 2:01
  it
• 2:01
  is
• 2:01
  true
• 2:02
  that
• 2:02
  in
• 2:03
  order
• 2:03
  to
• 2:03
  understand
• 2:05
  a
• 2:05
  question
• 2:05
  like
• 2:05
  this,
• 2:06
  it
• 2:06
  does
• 2:06
  help
• 2:06
  to
• 2:07
  become
• 2:07
  familiar
• 2:08
  with
• 2:09
  the
• 2:09
  different
• 2:09
  formulations
• 2:10
  and
• 2:10
  what
• 2:10
  they
• 2:10
  require
• 2:11
  because
• 2:11
  some
• 2:11
  of
• 2:11
  them
• 2:12
  absolutely
• 2:12
  do
• 2:13
  require
• 2:13
  an
• 2:14
  oral
• 2:14
  overlap
• 2:15
  and
• 2:15
  some
• 2:15
  of
• 2:15
  them
• 2:16
  don't.
• 2:16
  So
• 2:17
  that's
• 2:17
  not
• 2:17
  something
• 2:17
  you
• 2:18
  can
• 2:18
  necessarily
• 2:18
  intuitively
• 2:19
  know
• 2:20
  without
• 2:20
  understanding
• 2:21
  the
• 2:22
  unique
• 2:22
  formulation
• 2:24
  and
• 2:24
  when
• 2:24
  it
• 2:24
  releases
• 2:25
  the
• 2:25
  medications.
• 2:26
  Some
• 2:26
  of
• 2:26
  these
• 2:26
  have
• 2:26
  delayed
• 2:27
  release
• 2:28
  formulations
• 2:29
  where
• 2:29
  you
• 2:29
  do
• 2:30
  need
• 2:30
  an
• 2:30
  oral
• 2:30
  overlap
• 2:31
  and
• 2:31
  some
• 2:31
  of
• 2:31
  them
• 2:31
  don't.
• 2:32
  Some
• 2:32
  of
• 2:32
  them
• 2:32
  are.
• 2:33
  They.
• 2:33
  They
• 2:33
  come
• 2:33
  out
• 2:34
  with
• 2:34
  an
• 2:34
  immediate
• 2:35
  drug
• 2:35
  release
• 2:36
  where
• 2:36
  you
• 2:36
  don't
• 2:37
  need
• 2:37
  to
• 2:37
  bring
• 2:38
  an
• 2:38
  oval
• 2:38
  oral
• 2:39
  overlap
• 2:40
  with
• 2:40
  it.
• 2:41
  But
• 2:41
  the
• 2:41
  big
• 2:42
  picture
• 2:42
  here,
• 2:42
  my
• 2:42
  friends,
• 2:43
  to
• 2:43
  take
• 2:43
  away
• 2:44
  from
• 2:44
  lais,
• 2:45
  is
• 2:45
  that,
• 2:45
  you
• 2:46
  know,
• 2:46
  again,
• 2:46
  they
• 2:46
  have
• 2:47
  flip
• 2:47
  flop
• 2:47
  pharmacokinetics
• 2:48
  where
• 2:49
  the
• 2:49
  absorption
• 2:49
  is
• 2:50
  actually
• 2:50
  slower
• 2:51
  a
• 2:51
  lot
• 2:51
  of
• 2:51
  times
• 2:51
  because
• 2:52
  it's
• 2:52
  an
• 2:52
  intramuscular
• 2:53
  injection,
• 2:54
  right?
• 2:54
  And
• 2:54
  then
• 2:54
  it
• 2:55
  slowly
• 2:55
  absorbs
• 2:56
  through
• 2:56
  the
• 2:56
  muscle
• 2:56
  into
• 2:56
  the
• 2:56
  bloodstream.
• 2:57
  So
• 2:57
  it's
• 2:58
  slower.
• 2:59
  So
• 2:59
  sometimes
• 2:59
  it's
• 3:00
  too
• 3:00
  slow
• 3:01
  to
• 3:01
  where
• 3:01
  in
• 3:02
  certain,
• 3:02
  depending
• 3:03
  on
• 3:03
  the
• 3:03
  formulation,
• 3:04
  you
• 3:04
  still
• 3:04
  need
• 3:05
  some
• 3:05
  oral
• 3:05
  medications
• 3:07
  being
• 3:07
  given
• 3:07
  to
• 3:07
  your
• 3:07
  patient,
• 3:08
  otherwise
• 3:09
  their
• 3:09
  psychotic,
• 3:10
  psychotic
• 3:10
  symptoms
• 3:11
  are
• 3:11
  not
• 3:11
  going
• 3:11
  to
• 3:11
  be
• 3:11
  covered.
• 3:12
  Right.
• 3:12
  You're
• 3:12
  waiting
• 3:13
  for
• 3:13
  this
• 3:13
  slow
• 3:13
  absorption,
• 3:14
  and
• 3:15
  it's
• 3:15
  not
• 3:15
  fast
• 3:15
  enough
• 3:16
  to
• 3:16
  cover
• 3:17
  the
• 3:17
  psychiatric
• 3:18
  symptoms
• 3:18
  or
• 3:18
  to
• 3:18
  reach
• 3:18
  a
• 3:19
  steady
• 3:19
  state
• 3:19
  in
• 3:19
  time.
• 3:20
  So
• 3:20
  again,
• 3:20
  depending
• 3:21
  on
• 3:21
  the
• 3:21
  formulation,
• 3:22
  you
• 3:22
  may
• 3:22
  need
• 3:22
  to
• 3:23
  do
• 3:23
  an
• 3:23
  oral
• 3:24
  overlap.
• 3:24
  And
• 3:24
  that's
• 3:24
  what
• 3:25
  this
• 3:25
  question's
• 3:25
  really
• 3:26
  trying
• 3:26
  to
• 3:26
  tease
• 3:26
  out,
• 3:26
  if
• 3:27
  you
• 3:27
  know
• 3:27
  that
• 3:27
  or
• 3:27
  not.
• 3:28
  And
• 3:28
  the
• 3:28
  boards
• 3:28
  will
• 3:29
  probably
• 3:30
  want
• 3:30
  you
• 3:30
  to
• 3:30
  have
• 3:30
  some
• 3:30
  kind
• 3:31
  of
• 3:31
  familiarity
• 3:31
  with
• 3:32
  of
• 3:32
  the
• 3:32
  various
• 3:33
  formulations.
• 3:34
  So
• 3:35
  let's
• 3:35
  look
• 3:35
  at
• 3:36
  option
• 3:36
  C.
• 3:37
  Okay.
• 3:38
  Now
• 3:39
  option
• 3:40
  C
• 3:40
  is
• 3:41
  the
• 3:41
  first
• 3:41
  two
• 3:41
  injections
• 3:42
  must
• 3:42
  be
• 3:42
  given
• 3:42
  in
• 3:42
  the
• 3:43
  gluteal
• 3:43
  muscle
• 3:43
  to
• 3:44
  ensure
• 3:44
  slow
• 3:44
  sustained
• 3:45
  absorption.
• 3:46
  Well,
• 3:46
  here's
• 3:46
  a
• 3:46
  fun
• 3:46
  little
• 3:47
  pearl
• 3:47
  that
• 3:48
  is
• 3:48
  actually
• 3:48
  the
• 3:48
  opposite
• 3:49
  of
• 3:49
  what
• 3:49
  we
• 3:49
  need.
• 3:50
  Right.
• 3:50
  The
• 3:50
  first
• 3:50
  two
• 3:50
  loading
• 3:51
  doses
• 3:51
  of
• 3:52
  Invega
• 3:52
  sustaina
• 3:53
  must
• 3:53
  be
• 3:53
  given
• 3:53
  in
• 3:53
  the
• 3:53
  deltoid
• 3:54
  muscle,
• 3:54
  not
• 3:54
  the
• 3:55
  gluteal.
• 3:55
  The
• 3:56
  deltoid
• 3:56
  actually
• 3:56
  has
• 3:57
  higher
• 3:57
  blood
• 3:57
  flow,
• 3:57
  which
• 3:58
  produces
• 3:58
  faster
• 3:58
  absorption
• 3:59
  and
• 4:00
  higher
• 4:00
  initial
• 4:00
  plasma
• 4:01
  concentration,
• 4:02
  which
• 4:02
  we
• 4:02
  do
• 4:03
  need
• 4:03
  to
• 4:03
  achieve
• 4:03
  those
• 4:04
  rapidly
• 4:05
  therapeutic
• 4:05
  levels
• 4:06
  during
• 4:06
  the
• 4:06
  loading
• 4:07
  phase.
• 4:07
  Remember,
• 4:07
  it
• 4:08
  is
• 4:08
  a
• 4:08
  slow
• 4:09
  administration.
• 4:10
  The
• 4:10
  im.
• 4:10
  The
• 4:11
  IM
• 4:11
  administration
• 4:12
  is
• 4:12
  slower,
• 4:12
  it's
• 4:13
  more
• 4:13
  steady,
• 4:13
  there's
• 4:14
  steadier
• 4:14
  plasma
• 4:15
  levels.
• 4:15
  Okay.
• 4:16
  But
• 4:16
  we
• 4:16
  don't
• 4:16
  really
• 4:17
  want
• 4:18
  this
• 4:18
  to
• 4:18
  be
• 4:18
  too
• 4:19
  slow
• 4:19
  either.
• 4:20
  Right.
• 4:20
  And
• 4:21
  so
• 4:21
  if
• 4:21
  you
• 4:21
  can
• 4:22
  pick
• 4:22
  a
• 4:22
  site
• 4:23
  in
• 4:23
  this
• 4:23
  case
• 4:24
  for
• 4:24
  in
• 4:24
  Vega
• 4:24
  Sistana
• 4:25
  in
• 4:25
  the
• 4:25
  deltoid,
• 4:26
  that
• 4:27
  will
• 4:27
  result
• 4:28
  in
• 4:28
  less
• 4:29
  of
• 4:29
  a
• 4:30
  slower
• 4:31
  absorption.
• 4:31
  Again,
• 4:32
  you
• 4:32
  can
• 4:32
  get
• 4:32
  your
• 4:33
  patient
• 4:33
  to
• 4:33
  a
• 4:33
  steady
• 4:34
  state
• 4:34
  and
• 4:34
  or
• 4:35
  to
• 4:35
  therapeutic
• 4:35
  levels
• 4:36
  a
• 4:36
  little
• 4:36
  faster
• 4:37
  and
• 4:37
  maximize
• 4:38
  that
• 4:38
  loading
• 4:38
  dose.
• 4:39
  And
• 4:39
  so
• 4:39
  think
• 4:39
  deltoid.
• 4:40
  When
• 4:41
  we're
• 4:41
  thinking
• 4:42
  of
• 4:42
  faster
• 4:42
  absorption
• 4:43
  and
• 4:43
  higher
• 4:43
  initial
• 4:44
  plasma
• 4:44
  concentrations.
• 4:45
  Okay.
• 4:46
  And
• 4:46
  if
• 4:46
  you
• 4:46
  gave
• 4:46
  it
• 4:46
  in
• 4:47
  the
• 4:47
  gluteal,
• 4:47
  it
• 4:47
  would
• 4:48
  actually
• 4:48
  result
• 4:48
  in
• 4:48
  a
• 4:48
  28%
• 4:49
  roughly
• 4:50
  lower
• 4:51
  max
• 4:52
  plasma
• 4:52
  level.
• 4:53
  And
• 4:54
  that
• 4:54
  would
• 4:54
  be
• 4:54
  like
• 4:55
  a
• 4:55
  delay
• 4:55
  in
• 4:55
  your
• 4:56
  time
• 4:56
  to
• 4:56
  therapeutic
• 4:57
  efficacy.
• 4:57
  And
• 4:57
  that's
• 4:58
  a
• 4:58
  problem.
• 4:58
  Right.
• 4:59
  So
• 4:59
  we
• 5:00
  really
• 5:00
  want
• 5:01
  to
• 5:02
  start
• 5:02
  with
• 5:02
  the
• 5:02
  deltoid.
• 5:03
  Now,
• 5:04
  after
• 5:04
  the
• 5:04
  loading
• 5:04
  dose
• 5:05
  is
• 5:05
  over
• 5:05
  with
• 5:06
  in
• 5:06
  Vega,
• 5:07
  you're
• 5:07
  looking
• 5:07
  at
• 5:08
  day
• 5:08
  one
• 5:09
  of
• 5:09
  a
• 5:09
  specific
• 5:10
  dose,
• 5:10
  and
• 5:11
  then
• 5:11
  about
• 5:11
  a
• 5:11
  week
• 5:11
  later
• 5:12
  you're
• 5:12
  doing
• 5:12
  another
• 5:12
  dose.
• 5:13
  And
• 5:13
  then
• 5:13
  you
• 5:13
  kind
• 5:14
  of
• 5:14
  do
• 5:14
  monthly
• 5:14
  doses
• 5:15
  thereafter.
• 5:15
  Okay.
• 5:16
  So
• 5:17
  it's
• 5:17
  really,
• 5:17
  really
• 5:18
  day
• 5:18
  one
• 5:18
  is
• 5:18
  like
• 5:18
  234
• 5:19
  milligrams
• 5:20
  in
• 5:20
  the
• 5:20
  deltoid,
• 5:21
  and
• 5:21
  then
• 5:22
  on
• 5:22
  day
• 5:22
  eight,
• 5:22
  it's
• 5:23
  156
• 5:23
  milligrams
• 5:24
  in
• 5:24
  the
• 5:24
  deltoID.
• 5:25
  And
• 5:25
  again,
• 5:25
  you
• 5:25
  don't
• 5:26
  want
• 5:26
  to
• 5:26
  do
• 5:26
  the
• 5:26
  gluteal
• 5:27
  because
• 5:27
  that
• 5:27
  will
• 5:27
  result
• 5:27
  in
• 5:28
  a
• 5:28
  lower
• 5:29
  absorption
• 5:29
  and
• 5:30
  a
• 5:30
  slower
• 5:30
  absorption,
• 5:31
  and
• 5:31
  that
• 5:31
  it's
• 5:32
  going
• 5:32
  to
• 5:32
  mess
• 5:32
  with
• 5:32
  the
• 5:32
  entire
• 5:32
  pharmacokinetics
• 5:33
  of
• 5:33
  this
• 5:34
  entire
• 5:34
  operation
• 5:35
  here.
• 5:36
  So
• 5:36
  option
• 5:37
  C
• 5:37
  is
• 5:37
  wrong.
• 5:37
  It
• 5:38
  is
• 5:38
  in
• 5:38
  your
• 5:39
  face
• 5:39
  wrong.
• 5:39
  And
• 5:39
  if
• 5:40
  we
• 5:40
  know
• 5:40
  that
• 5:41
  little
• 5:41
  pearl,
• 5:41
  we
• 5:41
  can
• 5:42
  avoid
• 5:42
  that
• 5:42
  one
• 5:42
  in
• 5:42
  the
• 5:43
  future.
• 5:43
  Now,
• 5:43
  what
• 5:43
  about
• 5:44
  option
• 5:44
  D?
• 5:44
  Oral
• 5:45
  risperidone
• 5:46
  must
• 5:46
  be
• 5:46
  continued
• 5:46
  for
• 5:47
  21
• 5:48
  days
• 5:48
  after
• 5:48
  the
• 5:48
  first
• 5:49
  injection
• 5:49
  to
• 5:49
  bridge
• 5:50
  the
• 5:50
  gap
• 5:51
  to
• 5:51
  therapeutic
• 5:52
  levels.
• 5:53
  Well,
• 5:53
  option
• 5:53
  D
• 5:54
  is
• 5:54
  also
• 5:54
  not
• 5:55
  correct.
• 5:55
  Okay?
• 5:56
  It's
• 5:56
  actually
• 5:57
  describing
• 5:57
  the
• 5:58
  oral
• 5:58
  overlap
• 5:58
  required
• 5:59
  for
• 5:59
  a
• 5:59
  different
• 5:59
  lai,
• 6:00
  the
• 6:00
  respiratory
• 6:01
  lai.
• 6:01
  Okay,
• 6:02
  respiratory
• 6:02
  Consta.
• 6:03
  And
• 6:03
  it's
• 6:04
  not
• 6:04
  describing
• 6:05
  the
• 6:05
  specific
• 6:06
  protocol
• 6:06
  for
• 6:06
  invas.
• 6:08
  Okay?
• 6:08
  Consta
• 6:09
  does
• 6:09
  use
• 6:09
  a
• 6:10
  different
• 6:10
  technology
• 6:10
  and
• 6:11
  you
• 6:11
  don't
• 6:11
  have
• 6:11
  to
• 6:11
  go
• 6:11
  in
• 6:11
  the
• 6:11
  weeds
• 6:12
  with
• 6:12
  this
• 6:12
  too
• 6:12
  much.
• 6:12
  But
• 6:12
  it's
• 6:13
  a
• 6:13
  microsphere
• 6:13
  technology
• 6:14
  that,
• 6:15
  like
• 6:15
  I
• 6:15
  said
• 6:15
  in
• 6:15
  the
• 6:15
  beginning,
• 6:15
  kind
• 6:16
  of
• 6:16
  delays
• 6:16
  drug
• 6:16
  release
• 6:17
  by
• 6:17
  three
• 6:17
  weeks.
• 6:18
  Well,
• 6:18
  if
• 6:18
  you're
• 6:18
  delaying
• 6:19
  drug
• 6:19
  release
• 6:19
  for
• 6:19
  three
• 6:20
  weeks,
• 6:20
  it's
• 6:21
  pretty
• 6:21
  simple,
• 6:21
  right?
• 6:21
  You
• 6:22
  need
• 6:22
  oral
• 6:22
  medications
• 6:23
  to
• 6:23
  be
• 6:23
  given
• 6:23
  in
• 6:24
  that
• 6:24
  three
• 6:24
  week
• 6:24
  window
• 6:25
  or
• 6:25
  your
• 6:25
  patient's
• 6:26
  not
• 6:26
  going
• 6:26
  to
• 6:26
  have
• 6:26
  enough
• 6:27
  of
• 6:27
  a
• 6:27
  therapeutic
• 6:28
  blood
• 6:28
  level
• 6:28
  to
• 6:28
  contain
• 6:29
  the
• 6:29
  symptoms
• 6:29
  in
• 6:29
  front
• 6:30
  of
• 6:30
  them.
• 6:30
  So
• 6:30
  that's
• 6:31
  why
• 6:31
  Consta
• 6:32
  requires
• 6:33
  three
• 6:34
  weeks
• 6:34
  of
• 6:35
  constant
• 6:36
  medication
• 6:37
  before
• 6:38
  you
• 6:39
  stop
• 6:39
  the
• 6:39
  oral
• 6:39
  medication
• 6:40
  and
• 6:40
  then
• 6:41
  kind
• 6:41
  of
• 6:41
  enjoy
• 6:41
  the
• 6:42
  lai
• 6:42
  ride,
• 6:43
  if
• 6:43
  you
• 6:43
  will.
• 6:44
  Okay,
• 6:44
  but
• 6:45
  the
• 6:45
  medication
• 6:46
  we're
• 6:46
  talking
• 6:46
  about
• 6:46
  here
• 6:46
  is
• 6:47
  in
• 6:47
  Vegas
• 6:47
  Sustaina.
• 6:48
  And
• 6:48
  the
• 6:48
  loading
• 6:48
  dose
• 6:48
  on
• 6:48
  day
• 6:49
  one
• 6:49
  and
• 6:49
  day
• 6:49
  eight
• 6:50
  eliminates
• 6:50
  the
• 6:50
  need
• 6:51
  for
• 6:51
  oral
• 6:51
  overlap.
• 6:52
  Remember,
• 6:52
  we're
• 6:52
  doing
• 6:52
  it
• 6:52
  in
• 6:52
  the
• 6:53
  deltoid.
• 6:53
  The
• 6:53
  deltoid
• 6:54
  is
• 6:54
  absorbing
• 6:54
  it
• 6:54
  a
• 6:55
  little
• 6:55
  faster
• 6:55
  than
• 6:55
  the
• 6:55
  gluteal.
• 6:56
  And
• 6:56
  we
• 6:56
  have
• 6:57
  two
• 6:57
  loading
• 6:57
  doses,
• 6:58
  day
• 6:58
  one
• 6:58
  and
• 6:58
  day
• 6:58
  eight,
• 6:59
  expressly
• 7:00
  to
• 7:00
  have
• 7:00
  to
• 7:00
  avoid
• 7:01
  this
• 7:01
  oral
• 7:02
  overlap,
• 7:02
  right,
• 7:02
  because
• 7:03
  we're
• 7:03
  getting
• 7:03
  it
• 7:03
  in
• 7:03
  the
• 7:03
  system
• 7:04
  a
• 7:04
  little
• 7:04
  faster
• 7:04
  by
• 7:05
  loading
• 7:05
  it
• 7:06
  more
• 7:06
  proactively.
• 7:07
  So
• 7:07
  that's
• 7:07
  a
• 7:08
  really
• 7:08
  key.
• 7:09
  Now,
• 7:10
  what
• 7:10
  about
• 7:10
  option
• 7:10
  E?
• 7:11
  He
• 7:11
  must
• 7:12
  complete
• 7:12
  a
• 7:12
  two
• 7:12
  week
• 7:13
  oral
• 7:13
  invega
• 7:14
  trial
• 7:14
  and
• 7:14
  continue
• 7:15
  oral
• 7:15
  supplementation
• 7:16
  for
• 7:16
  21
• 7:16
  days
• 7:17
  after
• 7:17
  the
• 7:17
  first
• 7:17
  injection.
• 7:18
  Well,
• 7:18
  this
• 7:18
  is
• 7:19
  also
• 7:19
  incorrect,
• 7:20
  right,
• 7:20
  because
• 7:20
  it's
• 7:20
  kind
• 7:21
  of
• 7:21
  two
• 7:22
  problems
• 7:23
  in
• 7:23
  one.
• 7:23
  We
• 7:23
  already
• 7:24
  explained
• 7:24
  why
• 7:24
  we
• 7:25
  don't
• 7:25
  need
• 7:25
  the
• 7:25
  overlap
• 7:26
  for
• 7:26
  three
• 7:26
  weeks.
• 7:27
  That's
• 7:27
  not
• 7:27
  necessary.
• 7:28
  Based
• 7:28
  on
• 7:29
  the
• 7:29
  pharmacokinetics
• 7:30
  of
• 7:30
  Inviga
• 7:30
  Sustena,
• 7:31
  we
• 7:31
  don't
• 7:31
  need
• 7:31
  three
• 7:32
  weeks
• 7:32
  of
• 7:32
  oral
• 7:32
  coverage
• 7:33
  here.
• 7:33
  We're
• 7:33
  getting
• 7:34
  a
• 7:34
  pretty
• 7:34
  aggressive
• 7:35
  loading
• 7:35
  dose
• 7:35
  on
• 7:35
  day
• 7:36
  one
• 7:36
  and
• 7:36
  day
• 7:36
  eight.
• 7:37
  Okay,
• 7:37
  but
• 7:38
  another
• 7:38
  issue
• 7:38
  with
• 7:39
  this
• 7:39
  is
• 7:40
  we.
• 7:40
  We
• 7:40
  don't
• 7:40
  need
• 7:41
  an
• 7:41
  unnecessarily
• 7:42
  long
• 7:42
  oral
• 7:43
  trial.
• 7:43
  The
• 7:43
  point
• 7:43
  of
• 7:44
  an
• 7:44
  oral
• 7:44
  trial,
• 7:44
  right,
• 7:45
  is
• 7:45
  just
• 7:46
  to
• 7:46
  make
• 7:46
  sure
• 7:46
  Your
• 7:46
  patient
• 7:47
  is
• 7:47
  not
• 7:47
  going
• 7:47
  to
• 7:48
  have
• 7:48
  an
• 7:48
  adverse
• 7:48
  reaction
• 7:49
  to
• 7:49
  the
• 7:49
  Invega.
• 7:50
  Right.
• 7:50
  So
• 7:50
  before
• 7:50
  you
• 7:50
  give
• 7:51
  Invega
• 7:51
  systema
• 7:51
  in
• 7:52
  this.
• 7:52
  In
• 7:52
  this
• 7:52
  answer,
• 7:53
  right,
• 7:54
  you
• 7:54
  do
• 7:54
  want
• 7:54
  to
• 7:54
  make
• 7:54
  sure
• 7:55
  your
• 7:55
  patient
• 7:55
  can
• 7:55
  tolerate
• 7:56
  Invega
• 7:57
  or
• 7:57
  in
• 7:58
  this
• 7:58
  case,
• 7:58
  a
• 7:59
  Risperidone.
• 7:59
  Remember,
• 8:00
  Risperidone
• 8:00
  is
• 8:00
  the
• 8:01
  parent
• 8:01
  compound.
• 8:02
  So
• 8:02
  your
• 8:02
  patient,
• 8:03
  in
• 8:03
  this
• 8:03
  mock
• 8:04
  case
• 8:04
  study
• 8:04
  has
• 8:05
  already
• 8:05
  demonstrate
• 8:06
  they
• 8:06
  can
• 8:07
  take
• 8:07
  risperidol
• 8:08
  safely.
• 8:08
  They
• 8:09
  don't
• 8:09
  have
• 8:09
  a
• 8:09
  history
• 8:09
  of
• 8:09
  dystonia,
• 8:10
  aesthesia,
• 8:11
  allergic
• 8:11
  reactions
• 8:11
  to
• 8:12
  risperidone.
• 8:12
  So
• 8:13
  Risperidone
• 8:13
  is
• 8:13
  metabolized
• 8:14
  into
• 8:14
  Invega,
• 8:15
  in
• 8:16
  case
• 8:16
  you
• 8:16
  didn't
• 8:16
  know
• 8:16
  that.
• 8:16
  Right.
• 8:17
  That's
• 8:17
  a
• 8:17
  really
• 8:17
  cool
• 8:17
  pearl.
• 8:18
  So
• 8:18
  if
• 8:19
  the
• 8:19
  patient's
• 8:19
  been
• 8:19
  on
• 8:19
  Risperidone
• 8:20
  or
• 8:20
  Invega
• 8:21
  and
• 8:21
  they
• 8:21
  tolerated
• 8:22
  it
• 8:22
  well
• 8:22
  orally,
• 8:23
  you
• 8:23
  do
• 8:23
  not
• 8:23
  need
• 8:24
  to
• 8:24
  go
• 8:24
  any
• 8:24
  further.
• 8:25
  As
• 8:25
  long
• 8:25
  as
• 8:25
  they've
• 8:25
  tolerated
• 8:26
  it
• 8:26
  and
• 8:26
  you've.
• 8:27
  You've
• 8:27
  made
• 8:27
  sure
• 8:27
  they
• 8:28
  haven't
• 8:28
  had
• 8:28
  any
• 8:28
  of
• 8:28
  those
• 8:28
  bizarre
• 8:29
  major
• 8:30
  acute
• 8:30
  dystonic
• 8:31
  reactions
• 8:31
  or
• 8:32
  severe
• 8:32
  aesthesia
• 8:33
  after
• 8:33
  a
• 8:33
  certain
• 8:34
  number
• 8:34
  of
• 8:34
  days.
• 8:34
  You
• 8:34
  can
• 8:34
  just
• 8:35
  do
• 8:35
  the
• 8:35
  lai.
• 8:35
  You're
• 8:36
  not
• 8:36
  waiting
• 8:36
  to
• 8:36
  see
• 8:36
  if
• 8:37
  the
• 8:37
  oral
• 8:37
  trial
• 8:38
  helped
• 8:38
  them
• 8:38
  with
• 8:38
  psychosis.
• 8:39
  You're
• 8:39
  waiting
• 8:39
  to
• 8:39
  make
• 8:40
  sure
• 8:40
  that
• 8:40
  the
• 8:40
  oral,
• 8:41
  the
• 8:41
  brief
• 8:41
  oral
• 8:42
  medication
• 8:43
  did
• 8:43
  not
• 8:43
  induce
• 8:44
  immediate
• 8:45
  deal
• 8:45
  breaking
• 8:46
  side
• 8:46
  effects.
• 8:46
  So
• 8:46
  that's
• 8:46
  why
• 8:46
  option
• 8:47
  E
• 8:47
  is
• 8:47
  not
• 8:47
  correct.
• 8:48
  We
• 8:48
  don't
• 8:48
  need
• 8:49
  21
• 8:49
  days
• 8:49
  of
• 8:49
  drug
• 8:50
  overlap
• 8:50
  and
• 8:50
  we
• 8:50
  don't
• 8:51
  need
• 8:51
  a
• 8:51
  14
• 8:51
  day
• 8:52
  trial
• 8:52
  to
• 8:52
  establish
• 8:53
  that
• 8:53
  this
• 8:53
  is
• 8:53
  the
• 8:54
  right
• 8:54
  medication.
• 8:55
  Your
• 8:55
  patient's
• 8:55
  already
• 8:56
  proven
• 8:56
  that
• 8:56
  he's
• 8:57
  been
• 8:57
  on.
• 8:58
  He's
• 8:58
  been
• 8:58
  on
• 8:58
  Risperidone.
• 8:59
  And,
• 9:00
  and
• 9:00
  so
• 9:00
  we.
• 9:00
  We
• 9:00
  have
• 9:01
  proof
• 9:01
  that
• 9:01
  he
• 9:01
  can
• 9:01
  tolerate
• 9:02
  the
• 9:02
  inveiga
• 9:03
  because
• 9:03
  it's
• 9:03
  the
• 9:04
  invas
• 9:04
  kind
• 9:05
  of
• 9:05
  the
• 9:05
  baby
• 9:05
  compound
• 9:06
  of
• 9:06
  risperidone.
• 9:06
  Okay.
• 9:07
  It's
• 9:07
  the
• 9:07
  metabolite.
• 9:08
  We've
• 9:08
  gone
• 9:09
  over
• 9:09
  why
• 9:10
  C
• 9:10
  is
• 9:10
  wrong.
• 9:11
  Right?
• 9:11
  We
• 9:11
  the
• 9:11
  glute
• 9:12
  versus
• 9:12
  the
• 9:12
  deltoid.
• 9:13
  Now,
• 9:13
  why
• 9:14
  is
• 9:14
  a
• 9:14
  wrong?
• 9:14
  Okay,
• 9:15
  why
• 9:15
  is
• 9:15
  a.
• 9:15
  He
• 9:16
  must
• 9:16
  complete
• 9:16
  a
• 9:16
  14
• 9:17
  day
• 9:17
  oral
• 9:18
  inva
• 9:18
  trial
• 9:19
  before
• 9:19
  his
• 9:19
  first
• 9:20
  injection
• 9:20
  can
• 9:20
  be
• 9:20
  given.
• 9:20
  Well,
• 9:21
  we
• 9:21
  just
• 9:21
  answered
• 9:21
  that.
• 9:22
  Right?
• 9:22
  We
• 9:22
  got
• 9:22
  it.
• 9:23
  We.
• 9:25
  The
• 9:25
  FDA
• 9:25
  label
• 9:26
  on
• 9:26
  Invega
• 9:26
  states
• 9:26
  that
• 9:27
  tolerability
• 9:27
  can
• 9:27
  be
• 9:28
  established
• 9:28
  with
• 9:28
  either
• 9:28
  oral
• 9:29
  Risperidon
• 9:29
  or
• 9:30
  oral
• 9:30
  and
• 9:31
  vega.
• 9:31
  And.
• 9:32
  And
• 9:32
  we
• 9:32
  don't
• 9:32
  need
• 9:32
  an
• 9:32
  additional
• 9:33
  trial.
• 9:33
  He
• 9:33
  has
• 9:34
  that.
• 9:34
  And
• 9:35
  again,
• 9:35
  the
• 9:36
  loading
• 9:36
  dose
• 9:36
  is
• 9:37
  aggressive
• 9:37
  enough
• 9:37
  here
• 9:38
  to
• 9:38
  where
• 9:38
  we
• 9:38
  don't
• 9:39
  need
• 9:39
  overlap
• 9:39
  either.
• 9:40
  And
• 9:40
  we
• 9:40
  don't
• 9:40
  need
• 9:40
  to
• 9:40
  demonstrate
• 9:41
  any
• 9:41
  more
• 9:41
  than
• 9:41
  we
• 9:41
  already
• 9:42
  have.
• 9:42
  So
• 9:42
  that's
• 9:43
  all
• 9:43
  pretty
• 9:44
  darn
• 9:44
  awesome.
• 9:45
  Pretty
• 9:46
  darn
• 9:46
  clear.
• 9:46
  I
• 9:46
  like
• 9:47
  this
• 9:47
  board
• 9:47
  bomb
• 9:48
  because
• 9:48
  it's
• 9:48
  very
• 9:48
  high
• 9:49
  yield.
• 9:49
  There's
• 9:50
  the
• 9:50
  technique
• 9:51
  involved
• 9:51
  in
• 9:51
  giving
• 9:52
  the
• 9:52
  medication.
• 9:53
  You
• 9:53
  can
• 9:53
  appreciate
• 9:53
  the
• 9:54
  fact
• 9:54
  that
• 9:54
  there's
• 9:54
  different
• 9:54
  formulations
• 9:55
  that
• 9:55
  don't
• 9:56
  all
• 9:56
  immediately
• 9:57
  release
• 9:57
  the
• 9:57
  drug
• 9:58
  right
• 9:58
  away.
• 9:59
  There
• 9:59
  is
• 9:59
  delayed
• 10:00
  onset
• 10:00
  in
• 10:00
  case
• 10:01
  of
• 10:01
  respiratory
• 10:02
  canca
• 10:02
  of
• 10:02
  three
• 10:03
  weeks.
• 10:03
  Even
• 10:04
  the
• 10:04
  Invaga
• 10:04
  Astana.
• 10:05
  It's
• 10:05
  not
• 10:05
  like
• 10:05
  you're
• 10:05
  immediately
• 10:06
  going
• 10:06
  to
• 10:06
  contain
• 10:07
  psychotic
• 10:07
  symptoms.
• 10:08
  There's
• 10:09
  a
• 10:09
  loading
• 10:09
  dose,
• 10:09
  there's
• 10:10
  a
• 10:10
  pretty
• 10:10
  aggressive
• 10:10
  loading
• 10:11
  dose,
• 10:11
  but
• 10:11
  that
• 10:12
  too
• 10:12
  takes
• 10:12
  time
• 10:12
  to
• 10:12
  reach
• 10:13
  steady
• 10:13
  state.
• 10:13
  It
• 10:14
  just
• 10:14
  doesn't
• 10:14
  require
• 10:15
  Invega
• 10:15
  oral
• 10:16
  tablets
• 10:16
  to
• 10:16
  be
• 10:17
  taken
• 10:17
  with.
• 10:18
  Just
• 10:18
  needs
• 10:19
  to
• 10:19
  be
• 10:19
  demonstrated
• 10:19
  that
• 10:20
  they
• 10:20
  don't
• 10:20
  have
• 10:20
  adverse
• 10:21
  reactions
• 10:21
  prior
• 10:21
  to
• 10:22
  it.
• 10:22
  So
• 10:22
  remember,
• 10:23
  if
• 10:23
  you
• 10:23
  become
• 10:23
  a
• 10:23
  Patreon
• 10:24
  member,
• 10:24
  my
• 10:24
  friends,
• 10:25
  you
• 10:25
  will
• 10:25
  understand
• 10:26
  the
• 10:26
  how
• 10:26
  and
• 10:26
  the
• 10:26
  why
• 10:27
  of
• 10:27
  all
• 10:27
  of
• 10:27
  these
• 10:28
  things.
• 10:28
  And
• 10:28
  that's
• 10:28
  really
• 10:29
  what
• 10:30
  separates
• 10:30
  you
• 10:31
  between
• 10:31
  the
• 10:31
  good
• 10:32
  and
• 10:32
  the
• 10:32
  great
• 10:32
  clinicians,
• 10:33
  right?
• 10:33
  Patients
• 10:34
  smell
• 10:34
  you
• 10:34
  a
• 10:34
  mile
• 10:35
  away
• 10:35
  when
• 10:35
  you
• 10:36
  know
• 10:36
  the
• 10:36
  how
• 10:36
  and
• 10:36
  why
• 10:37
  of
• 10:37
  what
• 10:37
  you're
• 10:37
  doing.
• 10:37
  And
• 10:38
  that
• 10:38
  is
• 10:38
  why
• 10:38
  we
• 10:39
  created
• 10:39
  Patreon
• 10:40
  to
• 10:40
  empower
• 10:40
  you
• 10:41
  to
• 10:41
  be
• 10:41
  at
• 10:41
  the
• 10:41
  top
• 10:41
  of
• 10:42
  your
• 10:42
  game
• 10:42
  and
• 10:42
  know
• 10:43
  these
• 10:43
  details.
• 10:43
  It
• 10:44
  makes
• 10:44
  running
• 10:44
  your
• 10:45
  clinics
• 10:45
  a
• 10:45
  lot
• 10:46
  smoother.
• 10:46
  It
• 10:47
  improves
• 10:47
  your
• 10:47
  patient
• 10:48
  outcomes
• 10:48
  and
• 10:48
  it
• 10:48
  separates
• 10:49
  you
• 10:49
  from
• 10:49
  the
• 10:49
  fray
• 10:50
  because
• 10:50
  you
• 10:51
  know
• 10:51
  the
• 10:51
  how
• 10:51
  and
• 10:51
  why
• 10:51
  of
• 10:52
  what
• 10:52
  you're
• 10:52
  doing.
• 10:52
  You're
• 10:52
  not
• 10:52
  just
• 10:53
  following
• 10:53
  algos.
• 10:54
  And
• 10:54
  patients
• 10:55
  know
• 10:55
  that
• 10:55
  and
• 10:55
  they
• 10:56
  appreciate
• 10:56
  that.
• 10:57
  And
• 10:57
  so
• 10:57
  go
• 10:57
  to
• 10:58
  the
• 10:58
  Show
• 10:58
  Notes.
• 10:58
  If
• 10:58
  there's
• 10:59
  one
• 10:59
  thing
• 10:59
  you
• 10:59
  remember
• 10:59
  by
• 11:00
  the
• 11:00
  end
• 11:00
  of
• 11:00
  the
• 11:00
  day,
• 11:01
  go
• 11:01
  to
• 11:01
  our
• 11:01
  Show
• 11:01
  Notes
• 11:02
  and
• 11:02
  become
• 11:02
  a
• 11:02
  Patreon
• 11:02
  member.
• 11:03
  We'd
• 11:03
  love
• 11:03
  to
• 11:04
  have
• 11:04
  you.
• 11:04
  It's
• 11:04
  really
• 11:05
  a
• 11:05
  steal.
• 11:05
  It's
• 11:06
  a
• 11:06
  huge
• 11:06
  clinical
• 11:07
  library
• 11:07
  of
• 11:07
  resources
• 11:08
  like
• 11:08
  this
• 11:09
  broken
• 11:09
  down
• 11:09
  immediately
• 11:10
  at
• 11:10
  your
• 11:10
  fingertips.
• 11:11
  So
• 11:12
  without
• 11:12
  further
• 11:13
  ado,
• 11:13
  my
• 11:13
  friends,
• 11:13
  you
• 11:13
  all
• 11:14
  have
• 11:14
  a
• 11:14
  wonderful
• 11:15
  rest
• 11:15
  of
• 11:15
  your
• 11:15
  day.
• 11:16
  Thank
• 11:16
  you.
• 11:17
  Signing
• 11:18
  off,
• 11:18
  NPZ.