Expanding Your Schizophrenia Toolkit With Xanomeline-Trospium

In part 2 of this series on how Advanced Practice Providers (APPs) can best leverage antipsychotic interventions for the treatment of schizophrenia, Hara Oyedeji, APRN, PMHNP-BC, MSEd, unpacks the use and benefits of xanomeline-trospium as a treatment option for schizophrenia.

Oyedeji first discusses xanomeline-trospium as a muscarinic agonist and compares the treatment to traditional antipsychotic options. She then touches on the impact that xanomeline-trospium may have on the positive, negative, and cognitive symptoms of schizophrenia, underscoring why it can be such a helpful treatment option for clinicians to have in their toolkit. 

Catch up on part 1: Effectively Managing Clozapine for Treatment-Resistant Schizophrenia

For more expert insights, visit the Schizophrenia Excellence Forum.

Hara Oyedeji, APRN, PMHNP-BC, MSEd: Hello, my name is Hara Oyedeji. I am a psychiatric nurse practitioner out of Baltimore, Maryland and I have my Master of Science in Nursing and also a Master of Science in Education, so I am an educator first and foremost. I have my own group practice, Fortitude Wellness Group, and I absolutely love being able to interact, teach, and work with fellow nurse practitioners.

Psych Congress Network: How does the profile of xanomeline-trospium differ from traditional antipsychotics, and what potential advantages might it offer in terms of efficacy or tolerability? 

Oyedeji: So xanomeline-trospium is definitely something that is novel for us as nurse practitioners and we have to understand the science, as well as how schizophrenia has been treated. For a long time, we have only understood or been taught the story of dopamine, and while it definitely plays a role, xanomeline-trospium provides for us the start of a new frontier, a new beginning. It’s opening up the conversations when we think about the disease state of schizophrenia, how we treat it and how the pathways work, especially with the symptoms that we're looking at. Positive, negative, and cognitive. Why is it different? Well, we're looking at muscarinic agonism and the story of muscarinics really hasn't been shared with schizophrenia in our didactic lessons as nurses, as nurse practitioners, until now. We're starting to have that discussion and it's amazing. It’s different, but it offers us more options—that there isn't only one way for us to treat the symptoms. 

The other piece is that most of our agents, prior to xanomeline-trospium, has always been D2 antagonism, unless you're looking at something like clozapine, which is for treatment -resistant schizophrenia. So we've always looked at the story of treating or modulating dopamine postsynaptically. Now we can use muscarinic agonism to do that. And when we have those options, we're bypassing other pathways in the brain that have traditionally cost our patients in terms of the other side effects that exist. So if we have this new frontier looking at muscarinics, it really opens up other areas for us to say, “Can we treat other things?” And that's very exciting, so it's a really great time for us to be practicing on this verge of a new frontier.

There’s space, and there's a place, really, for our current agents that we have been using. So [xanomeline-trospium] is more for us to add into our toolkit. The idea that we're not just looking at modulating dopamine presynaptically, we can actually utilize modulation with muscarinic agonism, muscarinics in general, to treat not just positive symptoms, and that's the key, but negative symptoms and cognitive deficits. That is huge. Our current agents have always looked at positive symptoms, and that's what traditionally society thinks of when they think of schizophrenia. But the reality is schizophrenia is comprised of not just hallucinations, okay? It is the negative symptoms. It's that daily functioning. Are you able to interact with others? It's also the cognition—are you able to have social cognition and awareness? And we have now an opportunity to treat all 3 areas.

Hara Oyedeji, APRN, PMHNP-BC, MSEd, is a board-certified psychiatric nurse practitioner currently working in outpatient care with experience in inpatient and psychiatric hospital settings. She serves as owner, clinician and clinical preceptor in her private group practice, Fortitude Wellness Group, and is the Chief Operating Officer and Medical Director of a CARF accredited Outpatient Mental Health Clinic, Greater Chesapeake Health and Wellness in Baltimore City. Hara completed her undergraduate degree at Rutgers University and her Master’s degree in education from Monmouth University in New Jersey. She completed her Master’s degree in nursing from the University of Maryland with her Post-Master's training as a psychiatric mental health nurse practitioner from Drexel University.

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