Antipsychotic drug prescribing in the elderly is cause for concern

The OxyContin crisis: problematisation and responsibilisation strategies in addiction, pain, and general medicine journals

BACKGROUND

OxyContin(®) (Purdue Pharma, L.P., Stamford, CT) is now widely regarded as a drug of abuse fueling a larger opioid health crisis. While coverage in the North American press about OxyContin overwhelmingly focused upon the problems of related crime and addiction/misuse and the perspectives of law enforcement officials and police, coverage in those fields of medicine most intimately concerned with OxyContin-pain medicine and addiction medicine-was more nuanced.

METHODS

In this article, we draw upon the constructivist social problems tradition and Hunt's theory of moral regulation in a qualitative analysis of 24 medical journal articles. We compare and contrast pain medicine and addiction medicine representations of the OxyContin problem, the agents responsible for it, and proposed solutions.

RESULTS

While there are some significant differences, particularly concerning the nature of the problem and the agents responsible for it, both pain medicine and addiction medicine authors 'take responsibility' in ways that attempt to mitigate the potential appropriation of the issue by law enforcement and regulatory agencies.

CONCLUSIONS

The responses of pain medicine and addiction medicine journal articles represent strategic moves to recapture lost credibility, to retain client populations and tools necessary to their jobs, and to claim a seat at the table in responding to the OxyContin crisis.

Plasma clozapine and norclozapine in relation to prescribed dose and other factors in patients aged 65 years and over: data from a therapeutic drug monitoring service, 1996-2010

OBJECTIVE

To investigate the effect of dose and other factors on plasma clozapine concentrations in patients aged 65 years and over.

METHOD

Audit of clozapine therapeutic drug monitoring data, 1996-2010.

RESULTS

There were 1930 samples [778 patients, 363 men aged (median, range) 67 (65-100) years and 415 women aged 68 (65-90) years]. There was no significant difference in the mean plasma clozapine concentration between men (0.56 mg/l) and women (0.58 mg/l), although the mean dose was higher in men (323 mg/d) than women (264 mg/d). The higher proportion of men (46%) compared with women (37%) smokers could explain this finding. Overall, 32% of samples had plasma clozapine below, and 37% above, a target range of 0.35-0.60 mg/l. Overall, the median dose decreased from 300 (65-70 years) to 200 mg/d (age 85 years and over). However, prescription of >350 mg/d was associated with a 50% likelihood that the plasma clozapine would exceed 0.60 mg/l. For a subgroup of 196 patients (114 men, 82 women), mean plasma clozapine was significantly higher after age 65 despite significantly lower dosage.

CONCLUSION

Clozapine dosage in elderly patients should be reviewed regularly to minimise the risk of adverse effects.

Antidepressant and antipsychotic drug prescribing in Lombardy

Background – The patterns of antidepressant and antipsychotìc drag prescribing have rarely been studied in large and geographically defined catchment areas. In the present study we examined the prevalence and distribution of antidepressant and antipsychotic prescribing in Lombardy, a northern Italy region of nine million inhabitants. Methods – This study used the Regional Administrative Database of Lombardy. This database includes all prescriptions reimbursed by the National Health System in the population living in this region. All antidepressant and antipsychotic prescriptions dispensed from the 1st January to the 31st December 2001 were extracted and prevalence data calculated by dividing antidepressant and antipsychotic users by the total number of male and female residents in each age group. In addition, from the Regional database of hospital admissions we extracted all patients aged 65 or above with cerebrovascular-related outcomes for the year 2002. The two databases were linked anonymously with the aim of investigating the relationship between exposure to psychotropics and occurrence of cerebrovascular accidents in the elderly. Results – During the study period 404, 238 individuals were dispensed antidepressants, yielding a prevalence of use of 2.85 (95% CI 2.84, 2.87) per 100 males and 5.92 (95% CI 5.90, 5.94) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old individuals. The majority of individuals received a pharmacological treatment with selective-serotonin reuptake inhibitors only, slightly more than 12% received a treatment with tricyclic antidepressants. A total of 86, 187 subjects were dispensed antipsychotic agents, yielding a prevalence of use of 0.87 (95% CI 0.86, 0.88) per 100 males and 1.01 (95% CI 1.00, 1.02) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old subjects. Concerning the relationship between exposure to second-generation antipsychotics (SGAs) and occurrence of cerebrovascular (CBV) accidents, the analysis showed a significantly increased risk of CBV events in elderly subjects exposed to SGAs in comparison with those exposed to first-generation antipsychotics (FGAs) (3, 31%, 95% CI 2, 95–3, 69 vs. 2, 37%, 95% CI 2, 19–2, 57). Finally the analysis indicated no differences in the proportion of cerebrovascular events in elderly subjects exposed to TCAs and SSRIs. Conclusions – The very high rates of antidepressant and antipsychotic drug prescribing detected in late life suggest the need of characterising these individuals in terms of medical and psychiatric characteristics, needs and quality of life. It also suggests the need for pragmatic clinical trials, carried out in the general practice, with the aim of assessing whether antidepressants are effective in these conditions. The data provide preliminary epidemiological evidence that exposure to SGAs, in comparison with exposure to FGAs, significantly increased the risk of cerebrovascular accidents in the elderly.

Declaration of Interest: none.

Are antipsychotic prescribing patterns different in older and younger adults?: a survey of 1357 psychiatric inpatients in Toronto

OBJECTIVE

To compare antipsychotic prescribing patterns in younger (aged 59 years or younger) and older (aged 60 years or older) patients with psychotic or mood disorders.

METHOD

Pharmacy records of all patients discharged from the Centre for Addiction and Mental Health over a 21-month period were reviewed. A total of 1357 patients who were prescribed an antipsychotic at the time of their discharge were included in the analysis (956 with a primary psychotic disorder and 401 with a primary mood disorder). World Health Organization-defined daily doses were used as the standardized dosing unit.

RESULTS

Both in patients with a primary psychotic disorder and in patients with a primary mood disorder, the prescribing patterns were similar in older and younger patients, with no statistical difference in the proportions receiving first-generation antipsychotics, second-generation antipsychotics (SGAs), multiple antipsychotics, or long-acting (depot) antipsychotics. Overall, the mean daily antipsychotic doses were lower only in the older group of patients with a primary mood disorder. However, the mean dose of SGAs was about 30% lower in older patients in both diagnostic groups. Regardless of age, patients with a mood disorder were prescribed lower doses of antipsychotics than those with a psychotic disorder.

CONCLUSIONS

Our data suggest that older patients are prescribed lower antipsychotic dosages primarily when using SGAs. This finding emphasizes the need for dose-finding studies assessing both the efficacy and the safety of antipsychotics in older patients with a psychotic or mood disorder.

Prevalence, incidence and persistence of antipsychotic drug prescribing in the Italian general population: retrospective database analysis, 1999-2002

PURPOSE

To investigate the prevalence, incidence and persistence with antipsychotic drug therapy in a large and geographically defined catchment area of Italian general population.

METHODS

All antipsychotic drug prescriptions dispensed during 1999, 2000, 2001 and 2002 were extracted from an administrative prescription database covering a population of 2 640 379 individuals. Antipsychotic drug users were defined as patients who had at least one recorded prescription in the current year. New users were defined as patients receiving a first prescription without any recorded antipsychotic drug treatment in the previous 12 months. Prevalence data were calculated by dividing users by the total number of male and female residents in each age group. Incidence data were calculated as the number of new users divided by the person-time free from antipsychotic drugs in the current year. The cumulative persistence of each medication was calculated by dividing the total prescribed amount of antipsychotic drug by the recommended daily dose, according to each agent's defined daily dose (DDD).

RESULTS

A progressive rise in prevalence and incidence rates was observed during the 4-year period. In each census year, the prevalence and incidence of prescribing was higher in females than males, and progressively rose with age, with the highest rates in old and very old subjects. The analysis of persistence with therapy revealed that 3176 individuals (78.5%) were occasional antipsychotic drug users, and that occasional use was more frequent among individuals receiving conventional antipsychotic drugs than among individuals receiving novel antipsychotic drugs. This difference was not explained by differences in the occurrence of neurologic adverse reactions, as shown by the concurrent prescribing of anticholinergic drugs, which was fairly similar between the two groups of new drug users. Additionally, we found that conventioal antipsychotic drugs were more often used in older individuals, where occasional use is very frequent, while novel antipsychotic drugs were more often prescribed in young and adult individuals, where regular use is more frequent.

CONCLUSIONS

An epidemiologically relevant proportion of everyday individuals is annually exposed to antipsychotic drugs. The distribution of prevalence and incidence rates by age highlighted an emerging public health issue related to the adverse and beneficial consequences of antipsychotic drug exposure in the elderly. The finding that persistence with therapy was longer in new users of novel antipsychotic drugs compared with new users of conventional agents might be explained by the different demographic and clinical characteristics of individuals receiving these two drug classes and not by the different tolerability profile of these two drug classes.

Epidemiological impact of antidepressant and antipsychotic drugs on the general population

PURPOSE OF REVIEW

To analyse the prevalence of and sex and age distribution associated with antidepressant and antipsychotic drug exposure in the general population and to highlight recent epidemiological findings concerning specific adverse outcomes associated with drug exposure.

RECENT FINDINGS

Epidemiological studies indicate high rates of second-generation antidepressant and antipsychotic drug use in the general population. The use is more prevalent among women than among men, and in older rather than in younger age groups. A new pattern of adverse outcomes has been described in individuals exposed to newer agents, including a possible risk of suicidal acts in adults receiving second-generation antidepressants, the risk of cerebrovascular events in older individuals receiving second-generation antipsychotics and the risk of metabolic disturbances in individuals exposed to specific second-generation antipsychotics.

SUMMARY

The assessment of, and attention to, the development of specific adverse reactions in individuals exposed to second-generation psychotropic drugs may improve treatment outcomes.

Primary care use of antipsychotic drugs: an audit and intervention study

BACKGROUND

Concerns regarding the use of antipsychotic medication in secondary care suggested an examination of primary care prescribing.

AIM

To audit and intervene in the suboptimal prescribing of antipsychotic drugs to primary care patients.

DESIGN OF STUDY

Cross-sectional prevalence: subsequent open treatment intervention.

SETTING

Seven of the 29 practices in the Eastern Hull Primary Care Trust.

METHODS

Criteria for best practice were developed, against which prescribing standards were tested via audit. Patients identified as suboptimally prescribed for were invited to attend an expert review for intervention.

RESULTS

1 in 100 of 53,000 patients was prescribed antipsychotic treatment. Diagnoses indicating this were impossible to ascertain reliably. Half the regimes failed one or more audit criteria, leaving diagnosis aside. Few practices agreed to patients being approached: of 179 invitations sent, only 40 patients attended. Of 32 still taking an antipsychotic drug, 26 required changes. Mean audit criteria failed were 3.4, lack of psychotic disorder diagnosis and problematic side effects being most frequent. Changes were fully implemented in only 16 patients: reasons for complete or partial failure to implement recommendations included the wishes or inaction of patients and professionals, and worsening of symptoms including two cases of antipsychotic withdrawal syndrome.

CONCLUSION

Primary care prescribing of antipsychotic drugs is infrequent, but most is unsatisfactory. Intervention is hampered by pluralistic reluctance: even with expert guidance, rationalisation is not without risk. Use of antipsychotic drugs in primary care patients whose diagnosis does not warrant this should be avoided. HOW THIS FITS IN: This study adds to concerns regarding high levels of off-licence use of potentially harmful medication. It adds evidence of major difficulties in rationalizing suboptimal regimes despite expert input. Relevance to the clinician is that it is better to avoid such regimes in the first place especially if there is no clear 'exit strategy': if in doubt, seek a specialist opinion.

Antipsychotic drugs and QT prolongation

Antipsychotic drugs (AD) are effective and frequently prescribed to more females than males. AD may cause serious cardiovascular side-effects, including prolonged QT interval, eventually leading to torsades de pointes (TdP) and sudden death. Epidemiologic data and case-control studies indicate an increased rate of sudden death in psychiatric patients taking AD. This review summarizes current knowledge about the QT prolonging effects of AD and gives practical suggestions. Amisulpride, clozapine, flupenthixol, fluphenazine, haloperidol, melperone, olanzapine, perphenazine, pimozide, quetiapine, risperidone, sulpiride, thioridazine and ziprasidone cause a QT prolongation ranging from 4 ms for risperidone to 30 ms for thioridazine. Our knowledge about the QT-prolonging effects of many AD is still limited. Females are under-represented in most studies. Many studies were conducted or supported by pharmaceutical companies. To avoid prodysrhythmia caused by QT prolongation, other factors influencing QT interval have to be considered, such as other drugs affecting the same pathway, hypokalemia, hypomagnesemia, bradycardia, increased age, female sex, congestive heart failure and polymorphisms of genes coding ion channels or enzymes involved in drug metabolism. Because the response of a patient to AD is individual, an electrocardiogram recording the QT interval has to be performed at baseline, after AD introduction and after occurrence of any factor that might influence the QT interval.

Psychotropic drug epidemiology: the road travelled, the road ahead

Psychotropic drug epidemiology is a discipline developed to study the use and the effects of drugs in large numbers of individuals. It describes how drugs are prescribed and utilized, investigates reasons underlying prescriptions, and monitors outcomes and variables which may affect these outcomes. In this article the main purposes, study designs and limitations of current pharmacoepidemiological approaches are reviewed with the aim of assessing whether this discipline can constitute a permanent link between the experimental world of clinical trials and the real world of everyday prescribing. We support the notion that evidence generated in clinical practice, by means of pharmacoepidemiological studies, should increasingly be used to develop and suggest innovative research hypotheses to be subsequently tested in pragmatic experimental studies.

Past use of selective serotonin reuptake inhibitors and the risk of cerebrovascular events in the elderly

Treatment with selective serotonin reuptake inhibitors (SSRIs) has been associated with intracranial bleeding abnormalities. We investigated the relationship between past exposure to SSRIs and occurrence of cerebrovascular accidents in the elderly. From the regional database of hospital admissions of Lombardy, Italy, we extracted all patients aged 65 years or above with cerebrovascular-related outcomes for the year 2002. From the regional database of prescriptions reimbursed by the National Health Service, we extracted all patients aged 65 years or above who received antidepressant prescriptions during 2001. The two databases were linked anonymously using the individual patient code. The analysis showed that the proportion of cerebrovascular events in those exposed to SSRIs was 135/66 335 [0.20%, 95% confidence interval (CI) 0.17-0.24], whereas the proportion of cerebrovascular accidents in those exposed to tricyclic antidepressants (TCAs) was 28/18 620 (0.15%, 95% CI 0.09-0.21). After background group differences were controlled for, exposure to SSRIs did not increase the risk of accidents (adjusted odds ratio 1.31, 95% CI 0.87-1.97). Although the risk of cerebrovascular accidents is a rare but serious event that should carefully be monitored during antidepressant therapy, this study indicated an absence of difference between TCAs and SSRIs.