What are the medical considerations for patients requesting refills on aripiprazole (Abilify), divalproex (Depakote), duloxetine (Cymbalta), gabapentin (Neurontin), hydroxyzine (Vistaril) pamoate, and mirtazapine (Remeron)?

From the Guidelines

When considering refill requests for these medications, it is essential to prioritize monitoring for potential side effects, evaluating continued therapeutic need, and assessing adherence to minimize risks and optimize outcomes, as supported by recent guidelines and studies 1.

Medical Considerations for Each Medication

• Aripiprazole (Abilify): Monitoring for metabolic effects, movement disorders, and psychiatric symptom control is crucial, as noted in guidelines for managing psychiatric conditions 1.
• Divalproex (Depakote): Regular liver function tests, complete blood counts, and therapeutic drug monitoring are necessary to maintain levels within the therapeutic range, highlighting the importance of careful management 1.
• Duloxetine (Cymbalta): Evaluation of depression symptoms, side effects, and discontinuation syndrome risk is vital before renewal, especially given its potential for withdrawal symptoms 1.
• Gabapentin (Neurontin): Assessment should include efficacy for the intended indication, potential for misuse, and kidney function, considering its use in pain management and potential for abuse 1.
• Hydroxyzine (Vistaril): Review for appropriate use patterns, dependence concerns, and anticholinergic side effects, especially in older adults, is necessary due to its high number of refills and potential for misuse 1.
• Mirtazapine (Remeron): Monitoring for weight gain, sedation, and depression symptom control is important, as it is used for depression and has a unique side effect profile 1.

General Considerations

• Adherence assessment, drug interactions review, and evaluation of continued therapeutic need are critical before authorizing refills for all these medications.
• Gradual discontinuation is required for some medications, like divalproex and duloxetine, to prevent withdrawal symptoms.
• The potential for misuse and dependence should be considered, particularly with medications like gabapentin and hydroxyzine.
• Recent studies emphasize the importance of careful management and monitoring of these medications to minimize risks and optimize patient outcomes 1.

From the FDA Drug Label

Mirtazapine tablets may cause serious side effects, including: • Increased risk of suicidal thoughts or actions in some children and young adults Mirtazapine tablets, and other antidepressant medicines may increase suicidal thoughts or actions in some people 24 years of age and younger, especially within the first few months of treatment or when the dose is changed.

A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs

Atypical antipsychotic drugs have been associated with metabolic changes that include hyperglycemia/diabetes mellitus, dyslipidemia, and body weight gain.

When considering refills for the listed medications, key medical considerations include:

• Suicidal thoughts or actions: Patients taking mirtazapine should be monitored for increased risk of suicidal thoughts or actions, especially in children and young adults 2.
• Tardive dyskinesia: Patients taking aripiprazole should be monitored for signs and symptoms of tardive dyskinesia, a potentially irreversible condition 3.
• Metabolic changes: Patients taking aripiprazole should be monitored for metabolic changes, including hyperglycemia, dyslipidemia, and weight gain 3.
• Dose and treatment duration: The smallest effective dose and shortest treatment duration should be used to minimize the risk of adverse effects.
• Regular monitoring: Patients should be regularly monitored for changes in mood, behavior, and physical health, and for signs of adverse effects.
• Patient education: Patients should be educated on the potential risks and benefits of their medications, and on the importance of regular monitoring and follow-up appointments.

From the Research

Medical Considerations for Refills

The following medications have specific considerations for refills:

• Aripiprazole (ABILIFY) 5 MG Tab:
  • When combined with divalproex, it may be useful in preventing relapse of mood episodes in patients with bipolar I disorder 4
  • Combining with mirtazapine may accelerate the onset of antidepressant action in patients with treatment-resistant depression 5
  • Concomitant use with duloxetine may increase aripiprazole plasma concentrations, potentially requiring dose adjustments 6
• Divalproex (DEPAKOTE) 500 MG Tab EC:
  • Combination therapy with aripiprazole may be effective in preventing relapse of mood episodes in patients with bipolar I disorder 4
• Duloxetine (CYMBALTA) 40 MG Capsule Enteric Coated Particles:
  • May increase aripiprazole plasma concentrations when used concomitantly, potentially requiring dose adjustments 6
  • Previous studies have shown no significant interaction with risperidone or aripiprazole 7
• Gabapentin (NEURONTIN) 300 MG Caps:
  • No specific interactions or considerations mentioned in the provided studies
• Hydroxyzine pamoate (VISTARIL) 25 MG Caps:
  • No specific interactions or considerations mentioned in the provided studies
• Mirtazapine (REMERON) 15 MG Tab:
  • Combination therapy with aripiprazole may be useful in treatment-resistant depression, with mirtazapine having favorable effects on aripiprazole-induced akathisia 5

Refill Management

Effective management of prescription refills is crucial in primary care practices 8. A satisfactory method for managing prescription refills involves:

• Teaching patients to call the pharmacy first for prescription refills
• Accepting only fax requests from the pharmacy
• Allowing a nurse or medical assistant to make most refill decisions
• Documenting them in the chart immediately
• Responding back to the pharmacy by fax
• Relying on the pharmacy to notify the patient when the refill is ready 8