Tricyclic Antidepressants: Is Your Patient Taking Them? Observations on Adherence and Unreported Use Using Prescriber-Reported Medication Lists and Urine Drug Testing

Non-Adherence to Antidepressant Treatment and Related Factors in a Region of Spain: A Population-Based Registry Study

Antidepressants are a commonly prescribed psychotropic medication, and their use has increased in recent years. Medication non-adherence in patients with mental disorders is associated with worse health outcomes. A population-based registry study to assess antidepressant non-adherence during 2021 has been carried out. An indirect method based on the medication possession ratio (MPR) has been utilized. Patients with a MPR under 80% were classified as non-adherent. A multivariate logistic regression to identify non-adherence predictors has been used, considering sociodemographic (age, sex, institutionalization and urbanicity) and health related variables (diagnostics, antidepressant class, multiple prescribers, and polypharmacy). In 2021, 10.6% of the Castile and Leon population used antidepressants. These patients were institutionalized (7.29%), living in urban areas (63.44%), polymedicated with multiple prescribers (57.07%), and using serotonin selective reuptake inhibitors (SSRIs) (54.77%), other antidepressants (46.82%) or tricyclic antidepressants (TCAs) (13.76%). Antidepressants were prescribed mainly for depression (36.73%) and anxiety (29.24%). Non-adherence to antidepressants was more frequent in men (20.56%) than in woman (19.59%) and decreased with increasing age (32% up to 17 years old vs. 13.76% over 80 years old). TCAs were associated with the highest prevalence of non-adherence (23.99%), followed by SSRIs (20.19%) and other antidepressants (18.5%). Predictors of non-adherence in patients on antidepressants were: living in urban areas, using TCAs, and pain occurrence. Non-adherence to antidepressants decreases with aging. Being female, institutionalization, being polymedicated and having depression/anxiety alongside another psychiatric diagnosis are protective factors against non-adherence. The MPR is a robust indicator for the clinician to identify non-adherent patients for monitoring, and adopt any necessary corrective actions.

Hyphenated mass spectrometry techniques for assessing medication adherence: advantages, challenges, clinical applications and future perspectives

Nonadherence to prescribed pharmacotherapy is an understated public health problem globally and is costing many patients their chance to return to good health and healthcare systems billions. Clinicians need an accurate assessment of adherence to medications to aid the clinical decision-making process in the event of poor patient progress and to maximise the patient health outcomes from the drug therapies prescribed. An overview of indirect and direct methods used to measure medication adherence is presented, highlighting the potential for accurate measuring of drugs in biological samples using hyphenated mass spectrometry (MS) techniques to provide healthcare professionals with a reliable evidence base for clinical decision making. In this review we summarise published applications of hyphenated MS techniques for a diverse range of clinical areas demonstrating the rise in the use of such direct methods for assessing medication adherence. Although liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods using plasma, serum and urine samples are the most popular, in recent years increased attention has been given to liquid chromatography high-resolution mass spectrometry (LC-HRMS) methods and alternative biosample matrices including hair, saliva and blood microsamples. The advantages and challenges of using hyphenated MS techniques to address this healthcare problem are also discussed alongside future perspectives.

Effect of intravenous midazolam on cardiac parameters in acute tricyclic antidepressants poisoning

BACKGROUND

Midazolam is commonly and safely used in poisoning management and intensive care for the control of agitated poisoned patients. Despite the introduction of newer and safer antidepressants, tricyclic antidepressants (TCAs) are still prescribed and used in many countries due to their cost-effectiveness. Severe morbidity and mortality associated with these drugs arises largely from their well-documented cardiovascular toxicity. In this study we aimed to investigate the probable effect of midazolam on some hemodynamic indices in TCAs-poisoned patients.

METHODS

In this clinical trial, we have evaluated some cardiovascular and hemodynamic indices of 100 TCAs-poisoned patients whom were randomly allocated for receiving midazolam with a first loading dose of 0.1 mg/kg (2 mg/minute) followed by a 6-hour maintenance infusion of 0.1 mg/kg/h of the drug in dextrose-saline (3.33% of dextrose and 0.33% of NaCl) or placebo (dextrose-saline infusion without midazolam). Pulse rate, systolic/diastolic blood pressure, respiratory rate, neurologic status and the outcome of therapy for all patients were recorded at the time of admission and hourly for the next 6 hours.

RESULTS

There was a statistically significant reduction in the heart rate of the midazolam treated group after the first hour of hospital admission. There were no significant differences in the respiratory rate, central nervous system manifestations and other indices between the two groups.

CONCLUSION

Midazolam may reduce tachycardia (and its fatal consequences) in the first hour of admission in TCAs-poisoned patients.

Urine specimen detection of zolpidem use in patients with pain

This study examined zolpidem and concurrent opioid, benzodiazepine, other central nervous system (CNS) depressants, and alcohol use. Urine specimens were analyzed using liquid chromatography-mass spectrometry (LC-MS/MS). Specimens were tested for zolpidem (n = 71,919) and separated into a provider-reported medication list documenting (n = 5,257) or not documenting zolpidem use (n = 66,662). Zolpidem-positive specimens were further separated into reported and unreported use cohorts. The total number of zolpidem-positive specimens in the reported and unreported use cohorts was 3,391 and 3,190, respectively. Non-informed prescribers were 4.4% (3,190/71,919) among the general population and 48.5% (3,190/6,581) when only zolpidem users were considered. In the zolpidem user population, the most common concurrent opioids in both cohorts were hydrocodone and oxycodone. Alprazolam and clonazepam were higher in the unreported use cohort (P ≤ 0.05). The unreported use cohort also had a higher detection of zolpidem plus a benzodiazepine (49.7 vs. 46%; P ≤ 0.05), zolpidem plus an opioid and a benzodiazepine (40.8% vs. 37.4%; P ≤ 0.05) and zolpidem plus an opioid, a benzodiazepine, and an other CNS depressant (12.9 vs. 10.9%; P ≤ 0.05). Concurrent use of zolpidem, an opioid, a benzodiazepine and an other CNS depressant is prevalent in a pain patient population.