Invega however, I am surprised how many people are not using it. It's the only atypical I dont need to adjust for liver failure (which is common where I am Alcohol/Hep B/Hep C/Overdose of Tylenol).
I will admit that paliperidone does not require adjustment in regards to overt liver failure. But the dose may well require adjustment over time anyway for other reasons, like varying symptom severity due to changing CNS compromise from the liver failure.
Yes, there is a recommendation in the PDR for adjustment of dose in liver impairment, "the mean free fraction of risperidone in plasma was increased by about 35%". This would mean that a 6 mg/day dose is equivalent to 8.1 mg/day. The text does not say how serious was the liver impairment in the test subjects. Was it "mild elevation of liver enzymes" or ICU pts awaiting transplant?
It also says, "the pharmacokinetics of risperidone in subjects with liver disease were comparable to those in young healthy subjects...."
It seems the need for dosage adjustment was not due to reduction in metabolic capacity (P450 capacity), but due to reduction in plasma protein - thus reduced protein binding capacity, "because of the diminished concentration of both albumin and α1-acid glycoprotein."
I take that to mean that there would be no dosage adjustment necessary until there is a detectable drop in plasma protein levels - - which is almost never the case in the average outpt with hx of Alcohol/Hep B/Hep C. And my experience has been that such pts do not require signif. different dosing than pt's w/o such history. But adjusting the dose is a normal part of the practice of treating any patient who needs an antipsychotic, so being a bit more conservative with outpatients who have a history of potential liver problems shouldn't cause any serious difficulties. These are all things any psychiatrist would be thinking about while titrating
any antipsychotic to effect vs side-effects.
Risperidone costs my county $0.65 for 3 mg, $1.30 for 6 mg.
Invega costs my county $10.13 for 3mg, $15.21 for 9mg.
If I spend 1000% more than I have to (esp for a "theoretical" benefit), we cut therapists, case managers, housing assistance, transportation, etc., etc. We've already closed clinics, closed every clinic every Friday, cut back hours on Mon-Thurs, and cut other services. And all our clinics now refuse to see anyone who does not have Medicaid or Medicare. Those with no funding source are simply NOT seen anywhere outside the hospital. And there simply is no other outpt resource for the indigent in our county. None.
I'm not kidding. If a new pt goes into one of our MH clinics without Medicaid or Medicare, (s)he will NOT see a doctor (even in a true psychiatric emergency) and will be told not to come back. If there is any SI or serious psychotic symptoms, the police/EMS will be called to whisk the pt away to the hospital - even if that might well have been avoided by seeing an MD briefly just one time.
Even when the money for prescriptions comes out of someone else's budget (private pt's in a private practice, w/ private insur and Rx coverage), it's coming from somewhere and the pot available for treating patients somewhere in the system gets smaller or the premiums on everyone else get larger.
I cannot pretend to treat patients in a vacuum.
