Joe parks dd best practices 4 13 (2)

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Dr. Joe Parks works through pharmacological trends.

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Joe parks dd best practices 4 13 (2)

  1. 1. Best Practices for Best Outcomes<br />April 13, 2010<br />
  2. 2. Psychotropic Medication Utilization<br />
  3. 3. Antipsychotic Patterns<br />
  4. 4. Portion of Prescriptions Potentially Questionable <br />CMHC’s 6.3% - 17.5%<br />CPS Special Housing 18.0% - 22.6% <br /> Hab Centers 16.6% - 36.3%<br />
  5. 5.
  6. 6. Outlier Prescribing and Psychiatry Time<br />
  7. 7. Causes of Polypharmacy<br /><ul><li>Not Enough Psychiatry Coverage
  8. 8. Incorrect Diagnosis
  9. 9. Failed Tapers
  10. 10. Over reliance on medication as the sole treatment
  11. 11. Desperation </li></li></ul><li>
  12. 12. Negative Outcomes Associated with Polypharmacy<br /><ul><li>Drug Interactions
  13. 13. Increased Medication Errors
  14. 14. Increasing Difficulty Assessing Effect of Individual Medications
  15. 15. Increased Side Effects
  16. 16. Increased Mortality
  17. 17. Additional Medications for Side Effects
  18. 18. Cost</li></li></ul><li>Antipsychotic PolypharmacyMEDLINE search 1966-2007<br /><ul><li>Categorized by Study Population
  19. 19. Treatment Resistant (15 studies)
  20. 20. Non-Treatment Resistant (15 studies)
  21. 21. Included:
  22. 22. Randomized Controlled Trials, (9 trials)
  23. 23. Non- Randomized Controlled Trials (6 trials)
  24. 24. Non-Controlled Observational studies (15 studies)
  25. 25. Excluded:
  26. 26. Series without statistical analysis
  27. 27. case reports</li></li></ul><li>Limitations of Literature<br />Small sample Sizes<br />Short Duration<br />Limited Matching Characteristics<br />
  28. 28. Treatment Resistant Studies<br />
  29. 29. Treatment Resistant Studies by Medications Utilized<br />
  30. 30. Megna et. Al 2007<br /><ul><li>Only Study to show superiority of Multiple Antipsychotics in Treatment Resistant Psychosis without Clozapine or Non-US AP
  31. 31. Retrospective Chart Review of 26 patients
  32. 32. Second antipsychotic added after 4 months on mono-therapy
  33. 33. Outcomes
  34. 34. 26% reduction on BPRS and decreased PRN use
  35. 35. Increased side effects
  36. 36. None improved enough for discharge</li></li></ul><li>Non-Treatment Resistant Studies<br />
  37. 37. Non-Treatment Resistant Studies by Medications Utilized<br />
  38. 38. Nishikawa, et. al. 1985<br /><ul><li>Only Study to show superiority of Multiple Antipsychotics in Non-Treatment Resistant Psychosis without Clozapine or Non-US AP
  39. 39. Non-Randomized Controlled Trial
  40. 40. Compared pimozide/thioridazine polypharmacy with both as mono-therapy
  41. 41. Outcomes
  42. 42. Poly was superior to low dose mono
  43. 43. Poly was no better than higher dose mono
  44. 44. Signs of “overdose” more common with poly</li></li></ul><li>Three Adjunctive Studies<br /><ul><li>All in Non-Treatment Resistant Population
  45. 45. All had Metabolic Syndrome reduction as Primary Outcome
  46. 46. One Non-Controlled Observational Study
  47. 47. CLZ vs CLZ/quetiapine: poly did better
  48. 48. Two Non-Controlled Random Studies
  49. 49. Mono-SGA vs poly-SGA : no difference
  50. 50. CLZ vs CLZ/RIS : CLZ/RIS did worse </li></li></ul><li>Antipsychotic PolypharmacyMortality Studies<br /><ul><li>Waddington, et. Al. 1998
  51. 51. 10 year prospective inpatient schizophrenia study
  52. 52. RR associated with AP polypharmacy = 2.46
  53. 53. Adjusted for cumulative AP dose and years on APs
  54. 54. Joukamaa, et. Al. 2006
  55. 55. 17 year retrospective schizophrenia study
  56. 56. RR associated with AP polypharmacy = 2.50
  57. 57. Adjusted for age, gender, BMI, smoking, education, and multiple other factors</li></li></ul><li> Conclusions - What we know<br />Antipsychotic Polypharmacy improves when augmenting Clozapine in treatment Resistant Patients, but also increases side effects.<br />Antipsychotic Polypharmacy in Non-treatment Resistant Patients<br />No improvement in symptoms<br />More side effects<br />Higher Mortality<br />Adjunctive Antipsychotic Polypharmacy does not reduce metabolic side effects<br />
  58. 58. Limitations- What We Don’t Know<br />Efficacy of non-Clozapine SGA Polypharmacy in treatment resistant psychosis<br />Efficacy of Clozapine polypharmacy in non-treatment resistant psychosis<br />
  59. 59. Aripiprazole augmentation of Risperidone or Quetiapine<br />Correll, Kane, Goff et.al. June , 2008 Poster<br />16 week, double blind, placebo controlled RTC<br />323 patients on risperidone or quetiapine given aripiprazole or placebo<br />No improvement in symptoms with SGA polypharmacy <br />Mixed changes in side effects<br />
  60. 60.
  61. 61. Published Practice GuidelinesRegarding Antipsychotic Polypharmacy<br />Published Guide lines include<br />American Psychiatric Association<br />Expert Consensus Guideline Series<br />Texas Medication Algorithmns<br />PORT<br />All recommend use of more than one AP only:<br />After multiple trials of monotherapy<br />After trial of clozapine<br />
  62. 62. Justifications for Antipsychotic Polypharmacy<br />Clozapine Augmentation<br />A History of 3 or more failed Trials of monotherapy<br />Recommended Plan to taper to monotherapy <br />
  63. 63. §483.450(e) Standard: Drug Usage<br />(e)(1) The facility must not use drugs in doses that interfere with the individual client’s daily living activities. <br />(e)(2) Drugs used for control of inappropriate behavior must be approved by the interdisciplinary team andbe used only as an integral part of the client’s individual program plan that is directed specifically towards the reduction of and eventual elimination of the behaviors for which the drugs are employed.<br />http://www.cms.gov/manuals/downloads/som107ap_j_intermcare.pdf accessed 4.09.10<br />
  64. 64. §483.450(e) Standard: Drug Usage<br />(e)(3) Drugs used for control of inappropriate behavior must not be used until it can be justified that the harmful effects of the behavior clearly outweigh the potentially harmful effects of the drugs.<br />(e) (4)(i) Drugs used for control of inappropriate behavior must bemonitored closely,in conjunction with the physician and the drug regimen review requirementfor desired responses and adverse consequences by facility staff; and<br />http://www.cms.gov/manuals/downloads/som107ap_j_intermcare.pdf accessed 4.09.10<br />
  65. 65. §483.450(e) Standard: Drug Usage<br />(e)(4)(ii) Gradually withdrawn at least annually in a carefully monitored program conducted in conjunction with the interdisciplinary team, unless clinical evidence justifies that this is contraindicated<br />http://www.cms.gov/manuals/downloads/som107ap_j_intermcare.pdf accessed 4.09.10<br />
  66. 66. Spectrum of AP Side Effects<br />NMS<br />EPS<br />Prolactin<br />WBC<br /> Weight Gain <br />ANTIPSYCHOTIC<br />AGENTS<br /> Diabetes/DKA<br /> Sedation <br /> Lipids<br /> Seizures<br /> Anticholinergic<br /> Orthostasis<br />NMS = Neuroleptic Malignant Syndrome<br />
  67. 67. Relative Risk of Side Effects Among Agents<br />Professional Resources & Business Development<br />+++ substantial risk, ++ moderate risk, + mild risk, +/- minimal risk or insufficient data <br />Mueser KT, Jeste DV. in Clinical Handbook of Schizophrenia, 2008, Fuller M, Sajatovic M, in Psychotropic Drug Information Handbook 2009, Drug PIs <br />
  68. 68. Meaningful Medication Tapers<br />Polypharmacy – 2 or more in same class<br />25% dose reduction per month<br />Completely off in 6 – 9 months<br />Monotherapy – only one of that class<br />10% dose reduction per month<br />Completely off in 12 – 18 months<br />
  69. 69. But Our Patients are Sicker<br />

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