Antipsychotic Polypharmacy among Children and Young Adults in Office-Based or Hospital Outpatient Department Settings

Recent Updates on Risk and Management Plans Associated with Polypharmacy in Older Population

The concept of polypharmacy encompasses adverse drug reactions and non-adherence factors in elderly individuals. It also leads to the increased use of healthcare services and negative health outcomes. The problem is further alleviated by the odds of potentially inappropriate medications (PIM), which lead to the development of drug-related problems. Since polypharmacy is more commonly observed in the elderly population, urgency is required to introduce operative protocols for preventing and managing this problem. The family medicine model of care can be associated with favorable illness outcomes regarding satisfaction with consultation, treatment adherence, self-management behaviors, adherence to medical advice, and healthcare utilization. Hence, interventions built on family medicine models can provide significant support in improving the outcomes of the older population and their quality of life. In this regard, the authors have taken up the task of explaining the accessible resources which can be availed to improve the application of health care services in the field of geriatric medicine.

The Effectiveness of Lurasidone Add-On for Residual Aggressive Behavior and Obsessive Symptoms in Antipsychotic-Treated Children and Adolescents with Tourette Syndrome: Preliminary Evidence from a Case Series

Children and adolescents with Tourette syndrome may suffer from comorbid psychological and behavioral difficulties, primarily Attention-Deficit Hyperactivity Disorder-related manifestations including impulsive, aggressive, and disruptive behavior, and Obsessive-Compulsive Disorder-related disturbances. Often, such additional problems represent the major cause of disability, requiring their prioritization above the tic symptomatology. Here, we present six cases of children and adolescents with treatment-resistant Tourette syndrome aged 11–17 years, whose symptoms, especially the non-tic symptoms such as aggressive behavior and obsessive symptoms, failed to respond adequately to at least two different antipsychotics and, where deemed appropriate, to a combination with a medication with a different therapeutic indication or chemical class (e.g., antidepressant or anticonvulsant). Such symptomatic manifestations were significantly reduced by the time of the subsequent control visit planned 30 days later, by using lurasidone as an add-on therapy to risperidone or aripiprazole (all p ≤ 0.009). No significant neuromotor or metabolic side effects were reported in all cases in a follow-up period ranging from 4 months to 6 months, supporting the stability of the observed clinical improvement. While still investigational, the preliminary evidence presented here gives reason to hope that lurasidone could possibly be an effective option in Tourette syndrome, warranting further investigation of its potential benefits in neurodevelopmental conditions.

Psychotropic Polypharmacy in the US Pediatric Population: A Methodologic Critique and Commentary

Background: Psychotropic concomitant medication use for the treatment of youth with emotional and behavioral disorders has grown significantly in the U.S. over the past 25 years. The use of pharmacy claims to analyze these trends requires the following: age of the selected population, overlapping days of use, and precision of the outcome itself. This review will also address the gaps in reporting of pediatric psychotropic polypharmacy. Methods: An electronic literature search was undertaken for the period 2000 through 2020 using keywords such as "pediatric," "concomitant," "polypharmacy," "multiple medications," and "concurrent psychotropic"; Relevant references in textbooks were also used. Only English language and U.S. studies were included, resulting in 35 inter-class studies. Results: Studies were organized into seven groups according to data sources and clinical topics: (1) population surveys; (2a) multi-state publicly insured populations; (2b) single/two state studies; (3) privately insured populations; (4) diagnosed populations; (5) foster care populations; (6) special settings. Across 20 years it is apparent that pediatric psychotropic polypharmacy affects substantially more children and adolescents today than had been the case. As many as 300,000 youth now receive 3 or more classes concomitantly. The duration of concomitant use is relatively long, e.g., 69-89% of annual medicated days. Finally, more adverse event reports were associated with 3-class compared with 2-class drug regimens. Discussion: Factors that contribute to the growth of pediatric psychotropic polypharmacy include: (1) predominance of the biological model in psychiatric practice; (2) invalid assumptions on efficacy of combinations, (3) limited professional awareness of metabolic and neurological adverse drug events, and (4) infrequent use of appropriate deprescribing. Conclusion: A review of publications documenting U.S. pediatric psychotropic polypharmacy written over the last 20 years supports the need to standardize the methodologies used. The design of population-based studies should maximize information on the number of youth receiving regimens of 3-, 4-, and 5 or more concomitant classes and the duration of such use. Next, far more post-marketing research is needed to address the effectiveness, safety and tolerability of complex drug regimens prescribed for youngsters.

Coprescription of opioid and naloxone in office-based practice and emergency department settings in the United States

OBJECTIVES

The objective of the study was to estimate the national rates of naloxone coprescribing with opioids in office-based practice and emergency department (ED) settings in the United States (US).

STUDY DESIGN

This study is a cross-sectional study.

METHODS

We used the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets to estimate the national rates of naloxone coprescribing with opioids for the period 2014-2016. The analysis was stratified into office-based practice and ED settings. In ED settings, opioid and naloxone could be given to patients while they were in ED or as a prescription at discharge. Patients of all ages were considered for the analysis and sampling weights were applied to estimate national rates.

RESULTS

In office-based settings, 7918 sample visits included one or more opioid prescriptions (10.67 per 100 office visits). Of those, one included naloxone as a coprescription. In ED settings, the opioid prescription was given at discharge in 6124 sample visits (9.68 per 100 ED visits). Of those, two included naloxone as a coprescription. On the other hand, opioid was given to patients in the ED in 8811 sample visits (13.57 per 100 ED visits). Of those, 30 included naloxone as a coprescription.

CONCLUSIONS

The rates of naloxone coprescribing with opioids were extremely low in office-based and ED settings in the US. Expanding access to naloxone is a key component of the public health response to the opioid crisis. Based on our study findings, promoting the coprescription of naloxone with opioids may provide greater access to naloxone for those who are at risk of opioid overdose.

National Child Mental Health Quality Measures: Adherence Rates and Extent of Evidence for Clinical Validity

PURPOSE OF REVIEW

To provide an overview of the selection process and annual updates of the child mental health measures within the Child Core Set, describe national and statewide adherence rates, and summarize findings from a systematic literature review examining measure adherence rates and whether adherence is associated with improved clinical outcomes.

RECENT FINDINGS

Five national quality measures target child mental health care processes. On average, national adherence varied widely by state, and performance did not substantially improve during the past 5 years. Mean national adherence rates for the two measures related to timeliness of care were below 50%. For each measure, scientific evidence to support the association between adherence and improved clinical outcomes was scarce. Investment in academic-agency partnered research to standardize methods for publicly reporting adherence to national child mental health quality measures and validation of these measures should be a national priority for child healthcare research.