Vivitrol without PO

[vanfanal]

How many folks out there are giving Vivitrol without giving PO naltrexone. I know the info says that you don’t need to establish with PO, but I learned it was good practice to at least establish tolerability with a dose or two. Right now, where I am, there’s an PO naltrexone shortage, so I’ve been holding off on new vivitrol starts for that reason. And this is just for etoh, I’m not worried about opioids in these situations.

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[calvnandhobbs68]

How many folks out there are giving Vivitrol without giving PO naltrexone. I know the info says that you don’t need to establish with PO, but I learned it was good practice to at least establish tolerability with a dose or two. Right now, where I am, there’s an PO naltrexone shortage, so I’ve been holding off on new vivitrol starts for that reason. And this is just for etoh, I’m not worried about opioids in these situations.

Yeah I mean all it says is "not required" in the prescribing information but not that it's recommended. I just don't see a great justification if there were some adverse reaction from the long acting without at least giving a few doses of PO for any extended release non-oral medication...they're definitely gonna be able to get some (probably many) psychiatrist/addictions docs to testify that it's usual practice to make sure a patient tolerates PO before switching to a long acting version of something that lasts for a month.

If you were in a non-outpatient setting (inpatient, residential, even PHPish) where you can closely monitor someone for a little while then probably would be more justified even if they have an adverse reaction.

Didn't realize there was any PO naltrexone shortage, that's annoying.

 

[Bartelby]

I always do PO first. It's rare people have an issue with naltrexone but for those who do I wouldn't want to sign them up for a month of that right from the start.

 

[vanfanal]

Cool. I thought as much. Thanks guys.

 

[littlefred]

If it's for alcohol and no opioid use concern, decent baseline LFT's I'd go for it.

For opioids maybe do a naloxone challenge in the office, then Rx if feeling brave?

 

[calvnandhobbs68]

If it's for alcohol and no opioid use concern, decent baseline LFT's I'd go for it.

For opioids maybe do a naloxone challenge in the office, then Rx if feeling brave?

If you're gonna get LFTs anyway outpatient, that's gonna take a few days usually for patients to go get labs, why not have them take PO while you wait for labs to come back? If you're concerned about the labs, they just stop the PO and now you know they can tolerate it before you give a monthlong IM injection. The issue isn't just for opioid withdrawal, if they have some adverse reaction from the med itself you're now subjecting them to a continuous release of this for quite some time.

LFTs aren't recommended anymore prior to starting naltrexone anyway though.

 

[littlefred]

If you're gonna get LFTs anyway outpatient, that's gonna take a few days usually for patients to go get labs, why not have them take PO while you wait for labs to come back? If you're concerned about the labs, they just stop the PO and now you know they can tolerate it before you give a monthlong IM injection. The issue isn't just for opioid withdrawal, if they have some adverse reaction from the med itself you're now subjecting them to a continuous release of this for quite some time.

LFTs aren't recommended anymore prior to starting naltrexone anyway though.

The OP said there's a PO shortage hence my post. If there were PO I wouldn't wait for LFT to start.

Can you give me a source on the last comment? I usually don't test anyway, but would love to have backing to my laziness lol

 

[calvnandhobbs68]

The OP said there's a PO shortage hence my post. If there were PO I wouldn't wait for LFT to start.

Can you give me a source on the last comment? I usually don't test anyway, but would love to have backing to my laziness lol

Let Me Google That

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[littlefred]

Let Me Google That

For all those people that find it more convenient to bother you with their question than to google it for themselves.

letmegooglethat.com

Very helpful!

On a serious note for other readers, benefit>risk and usually the only contraindication for NTX should be active liver failure.
Becomes a chicken or the egg conversation with regards to what's causing elevated liver enzymes.

 

[calvnandhobbs68]

Very helpful!

On a serious note for other readers, benefit>risk and usually the only contraindication for NTX should be active liver failure.
Becomes a chicken or the egg conversation with regards to what's causing elevated liver enzymes.

I'm assuming it was helpful considering the first 2-3 links are the actual guidelines which state there is no need for routine LFTs and provide the justification for doing so. It's pretty annoying when people want you to do their lit searches for them "to have backing to my laziness".

 

[littlefred]

I'm assuming it was helpful considering the first 2-3 links are the actual guidelines which state there is no need for routine LFTs and provide the justification for doing so. It's pretty annoying when people want you to do their lit searches for them "to have backing to my laziness".

Sorry for asking about medical literature of a medical claim made in a physician forum.

Asshat.

 

[calvnandhobbs68]

Sorry for asking about medical literature of a medical claim made in a physician forum.

Asshat.

When there is actual national society/agency guidance about a topic (PCSS is a SAMHSA funded program which puts out guidelines), it's often helpful to be familiar with the guidance, especially if you're treating the addressed disorders. It's like asking about something you can lookup in CANMAT guidelines.

 

[Stagg737]

Shortage of PO med is one of the few times I could see going straight to an LAI, but I still wouldn't do it unless they've failed most other options (which would be odd since naltrexone is often 1st or 2nd line). Side story, my dad got a steroid injection for a shoulder issue and had an allergic reaction (true mild-moderate anaphylaxis) with it. He had to go to the ER for acute treatment then take high-dose antihistamines for over a month afterward. Was a total freak thing but turns out he's allergic to some steroids and that's how we found out. When there's an easy PO option that can be used to test tolerance and it isn't, imo you're just opening yourself up to liability if something goes wrong.

 

[comp1]

This is scary. It's honestly scary the prescribing guidelines don't require PO first. I mean I have to do an oral trial and invega sustenna x4 before I can do hafyera, but we just put vivitrol (which has a lot less demonstrated efficacy) right into people? Like others have said, just the allergy concerns alone should require oral.

 

[psycho-matic]

Yeah I mean all it says is "not required" in the prescribing information but not that it's recommended. I just don't see a great justification if there were some adverse reaction from the long acting without at least giving a few doses of PO for any extended release non-oral medication...they're definitely gonna be able to get some (probably many) psychiatrist/addictions docs to testify that it's usual practice to make sure a patient tolerates PO before switching to a long acting version of something that lasts for a month.

If you were in a non-outpatient setting (inpatient, residential, even PHPish) where you can closely monitor someone for a little while then probably would be more justified even if they have an adverse reaction.

Didn't realize there was any PO naltrexone shortage, that's annoying.

I've been dealing with this shortage too in certain states, and have restored to gabapentin in states where it's not controlled or topiramate.

 

[Merovinge]

This is scary. It's honestly scary the prescribing guidelines don't require PO first. I mean I have to do an oral trial and invega sustenna x4 before I can do hafyera, but we just put vivitrol (which has a lot less demonstrated efficacy) right into people? Like others have said, just the allergy concerns alone should require oral.

I would agree to disagree. Rates of side effects to naltrexone are markedly less than the antipsychotics, in fact there are very few medications with as easy of a tolerability profile. Of course I would still take some PO first to ensure lack of allergy, but in the event that PO is not available and a person wants this treatment, it is a potentially life saving medication. I'm not saying this is the case for you, but this does sort of feel like medication for real psychiatry like schizophrenia is effective but treatment for addiction is poo poo.

 

[sloh]

Shortage of PO med is one of the few times I could see going straight to an LAI, but I still wouldn't do it unless they've failed most other options (which would be odd since naltrexone is often 1st or 2nd line). Side story, my dad got a steroid injection for a shoulder issue and had an allergic reaction (true mild-moderate anaphylaxis) with it. He had to go to the ER for acute treatment then take high-dose antihistamines for over a month afterward. Was a total freak thing but turns out he's allergic to some steroids and that's how we found out. When there's an easy PO option that can be used to test tolerance and it isn't, imo you're just opening yourself up to liability if something goes wrong.

Wow he had to take high dose anti-histamines for over 1 month from 1 steroid shot?

 

[Stagg737]

Wow he had to take high dose anti-histamines for over 1 month from 1 steroid shot?

Yup. Not so much for airway, but he was on 50-100mg of benadryl TID-QID. Even with that his shoulder/chest/torso had noticeable hives I could see obviously via facetime. He's taken allergy shots for decades for environmental allergies. We/they thought maybe it was something in the IM formulation because he'd taken steroids before, but he got a PO steroid taper months later and had to go to the ER for severe anaphylaxis (throat starting closing up) after 1 dose, so no more steroids for him.

Ironically he had eye surgery late last year and the ophtho initially refused to do it unless he took steroid drops for his eyes post-procedure. I had to call them myself and explain his history and reactions before they'd agree to do the surgery because they didn't believe someone could have a true allergy to steroids...

 

[FlowRate]

When there is actual national society/agency guidance about a topic (PCSS is a SAMHSA funded program which puts out guidelines), it's often helpful to be familiar with the guidance, especially if you're treating the addressed disorders. It's like asking about something you can lookup in CANMAT guidelines.

It's funny, when I had this argument several years ago, the PCSS guidance you are referring to had been put out, but ASAM and some other big organizations hadn't yet updated their guidelines about LFT testing prior to prescribing naltrexone, so I was "wrong" at the time. With the brief time I had to try and do some googling and professional society website-searching just now (not as straightforward as you imply if you're trying to find anything other than the PCSS guidelines), seems like maybe things are coming around to agreeing with PCSS, (UTD is in line, but statpearls is not, ASAM is unclear with the limited things I found in said limited time.)

 

[sloh]

Yup. Not so much for airway, but he was on 50-100mg of benadryl TID-QID. Even with that his shoulder/chest/torso had noticeable hives I could see obviously via facetime. He's taken allergy shots for decades for environmental allergies. We/they thought maybe it was something in the IM formulation because he'd taken steroids before, but he got a PO steroid taper months later and had to go to the ER for severe anaphylaxis (throat starting closing up) after 1 dose, so no more steroids for him.

Ironically he had eye surgery late last year and the ophtho initially refused to do it unless he took steroid drops for his eyes post-procedure. I had to call them myself and explain his history and reactions before they'd agree to do the surgery because they didn't believe someone could have a true allergy to steroids...

Did he find the Benadryl sedating taking it regularly?

 

[ObsequiousAplomb]

Did he find the Benadryl sedating taking it regularly?

Idk about his dad but when I have had to take Benadryl 150 TID for hives the last thing on my mind was whether or not it was sedating. I think I did find it sedating the first 2-3 days though, and I was so glad of those two days of rest.

 

[Stagg737]

Did he find the Benadryl sedating taking it regularly?

Not overly. He was still pretty uncomfortable, so that was keeping him more alert. It was mostly just keeping him from going nuts with itching and overactivation.