Psychotropic medicine prescribing and polypharmacy for people with dementia entering residential aged care: the influence of changing general practitioners.

OBJECTIVE: To examine relationships between changing general practitioner after entering residential aged care and overall medicines prescribing (including polypharmacy) and that of psychotropic medicines in particular. DESIGN: Retrospective data linkage study. SETTING, PARTICIPANTS: 45 and Up Study participants in New South Wales with dementia who were PBS concession card holders and entered permanent residential aged care during January 2010 - June 2014 and were alive six months after entry. MAIN OUTCOME MEASURES: Inverse probability of treatment-weighted numbers of medicines dispensed to residents and proportions of residents dispensed antipsychotics, benzodiazepines, and antidepressants in the six months after residential care entry, by most frequent residential care GP category: usual (same as during two years preceding entry), known (another GP, but known to the resident), or new GP. RESULTS: Of 2250 new residents with dementia (mean age, 84.1 years; SD, 7.0 years; 1236 women [55%]), 625 most frequently saw their usual GPs (28%), 645 saw known GPs (29%), and 980 saw new GPs (44%). The increase in mean number of dispensed medicines after residential care entry was larger for residents with new GPs (+1.6 medicines; 95% CI, 1.4-1.9 medicines) than for those attended by their usual GPs (+0.7 medicines; 95% CI, 0.4-1.1 medicines; adjusted rate ratio, 2.42; 95% CI, 1.59-3.70). The odds of being dispensed antipsychotics (adjusted odds ratio [aOR], 1.59; 95% CI, 1.18-2.12) or benzodiazepines (aOR, 1.69; 95% CI, 1.25-2.30), but not antidepressants (aOR, 1.32; 95% CI, 0.98-1.77), were also higher for the new GP group. Differences between the known and usual GP groups were not statistically significant. CONCLUSIONS: Increases in medicine use and rates of psychotropic dispensing were higher for people with dementia who changed GP when they entered residential care. Facilitating continuity of GP care for new residents and more structured transfer of GP care may prevent potentially inappropriate initiation of psychotropic medicines.

Patient access to chronic medications during the Covid-19 pandemic: Evidence from a comprehensive dataset of US insurance claims.

Patient access and adherence to chronic medications is critical. In this work, we evaluate whether disruptions related to Covid-19 have affected new and existing patients' access to pharmacological therapies without interruption. We do so by performing a retrospective analysis on a dataset of 9.4 billion US prescription drug claims from 252 million patients from May, 2019 through August, 2020 (about 93% of prescriptions dispensed within those months). Using fixed effect (conditional likelihood) linear models, we evaluate continuity of care, how many days of supply patients received, and the likelihood of discontinuing therapy for drugs from classes with significant population health impacts. Findings indicate that more prescriptions were filled in March 2020 than in any prior month, followed by a significant drop in monthly dispensing. Compared to the pre-Covid era, a patient's likelihood of discontinuing some medications increased after the spread of Covid: norgestrel-ethinyl estradiol (hormonal contraceptive) discontinuation increased 0.62% (95% CI: 0.59% to 0.65%, p<0.001); dexmethylphenidate HCL (ADHD stimulant treatment) discontinuation increased 2.84% (95% CI: 2.79% to 2.89%, p<0.001); escitalopram oxalate (SSRI antidepressant) discontinuation increased 0.57% (95% CI: 0.561% to 0.578%, p<0.001); and haloperidol (antipsychotic) discontinuation increased 1.49% (95% CI: 1.41% to 1.57%, p<0.001). In contrast, the likelihood of discontinuing tacrolimus (immunosuppressant) decreased 0.15% (95% CI: 0.12% to 0.19%, p<0.001). The likelihood of discontinuing buprenorphine/naloxone (opioid addiction therapy) decreased 0.59% (95% CI: 0.55% to 0.62% decrease, p<0.001). We also observe a notable decline in new patients accessing these latter two therapies. Most US patients were able to access chronic medications during the early months of Covid-19, but still were more likely to discontinue their therapies than in previous months. Further, fewer than normal new patients started taking medications that may be vital to their care. Providers would do well to inquire about adherence and provide prompt, nonjudgmental, re-initiation of medications. From a policy perspective, opioid management programs seem to demonstrate a robust ability to manage existing patients in spite of disruption.

Practical and Regulatory Considerations of Teleprescribing via CVT.

PURPOSE OF REVIEW: Clinical video teleconferencing (CVT) represents a robust mechanism for more accessible medical care. Providers who practice medicine via CVT, including teleprescribing, should understand a number of core practical and regulatory factors. This paper aims to review these core factors, such that providers new to CVT may offer teleprescribing services in a manner consistent with current clinical standards and regulatory requirements. RECENT FINDINGS: A number of practical factors relate to the setup and delivery of teleprescribing services that are contextually influenced by federal and state law. This review will elucidate the practical and regulatory factors relevant to teleprescribing and encourage the use of CVT for patient care. Through consideration of these factors, providers may better implement teleprescribing and prepare for future technology and policy changes relevant to practice.

A mixed methods analysis of clozapine errors reported to the National Reporting and Learning System.

PURPOSE: To review and analyse medication errors related to clozapine, an atypical antipsychotic, that were reported to the National Reporting and Learning System (NRLS). METHODS: Following extraction of one year of clozapine related errors from the NRLS, a qualitative analysis (thematic analysis and re-classification) and quantitative analysis was performed. An incident was considered a clozapine error if there was a failure in its medication process (i.e. an error in the prescribing, dispensing, preparing, administering, monitoring or advising of clozapine). RESULTS: "Issues with stock/supply/ordering" was the most common theme derived from the qualitative thematic analysis (n = 338), followed by wrong dose/strength/frequency (n = 221) and medication omissions (n = 202). Most errors occurred in the "administration/supply" medication stage. Over half of reported clozapine incidents involved people 26 to 55 years old (n = 830) and 82% of errors were reported by mental health services (n = 1270). Only 1.5% of reports were classed as moderate/severe harm. CONCLUSION: Issues with availability, stock, and supply were found to be the most common causes. This usually entailed a lack of stock to fulfil a patient's dose/supply. Such incidents could potentially be reduced by improved management of the supply process, and liaison between pharmacy and clinical staff. The implementation of emergency drug cupboards at the discretion of an on-call pharmacist may prove to be a preventative measure for such errors. Despite the potential adverse effects associated with clozapine, very few incidents led to moderate/severe harm. Encouragement of NRLS reporting is recommended for incidents of all degrees of harm.

Clozapine dose for schizophrenia.

BACKGROUND: Schizophrenia and related disorders such as schizophreniform and schizoaffective disorder are serious mental illnesses characterised by profound disruptions in thinking and speech, emotional processes, behaviour and sense of self. Clozapine is useful in the treatment of schizophrenia and related disorders, particularly when other antipsychotic medications have failed. It improves positive symptoms (such as delusions and hallucinations) and negative symptoms (such as withdrawal and poverty of speech). However, it is unclear what dose of clozapine is most effective with the least side effects. OBJECTIVES: To compare the efficacy and tolerability of clozapine at different doses and to identify the optimal dose of clozapine in the treatment of schizophrenia, schizophreniform and schizoaffective disorders. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (August 2011 and 8 December 2016). SELECTION CRITERIA: All relevant randomised controlled trials (RCTs), irrespective of blinding status or language, that compared the effects of clozapine at different doses in people with schizophrenia and related disorders, diagnosed by any criteria. DATA COLLECTION AND ANALYSIS: We independently inspected citations from the searches, identified relevant abstracts, obtained full articles of relevant abstracts, and classified trials as included or excluded. We included trials that met our inclusion criteria and reported useable data. For dichotomous data, we calculated the relative risk (RR) and the 95% confidence interval (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) again based on a random-effects model. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. MAIN RESULTS: We identified five studies that could be included. Each compared the effects of clozapine at very low dose (up to 149 mg/day), low dose (150 mg/day to 300 mg/day) and standard dose (301 mg/day to 600 mg/day). Four of the five included studies were based on a small number of participants. We rated all the evidence reported for the main outcomes of interest as low or very low quality. No data were available for the main outcomes of global state, service use or quality of life. Very low dose compared to low doseWe found no evidence of effect on mental state between low and very low doses of clozapine in terms of average Brief Psychiatric Rating Scale-Anchored (BPRS-A) endpoint score (1 RCT, n = 31, MD 3.55, 95% CI -4.50 to 11.60, very low quality evidence). One study found no difference between groups in body mass index (BMI) in the short term (1 RCT, n = 59, MD -0.10, 95% CI -0.95 to 0.75, low-quality evidence). Very low dose compared to standard doseWe found no evidence of effect on mental state between very low doses and standard doses of clozapine in terms of average BPRS-A endpoint score (1 RCT, n = 31, MD 6.67, 95% CI -2.09 to 15.43, very low quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 58, MD 0.10, 95% CI -0.76 to 0.96, low-quality evidence) Low dose compared to standard doseWe found no evidence of effect on mental state between low doses and standard doses of clozapine in terms of both clinician-assessed clinical improvement (2 RCTs, n = 141, RR 0.76, 95% CI 0.36 to 1.61, medium-quality evidence) and clinically important response as more than 30% change in BPRS score (1 RCT, n = 176, RR 0.93, 95% CI 0.78 to 1.10, medium-quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 57, MD 0.20, 95% CI -0.84 to 1.24, low-quality evidence).We found some evidence of effect for other adverse effect outcomes; however, the data were again limited. Very low dose compared to low doseThere was limited evidence that serum triglycerides were lower at low-dose clozapine compared to very low dose in the short term (1 RCT, n = 59, MD 1.00, 95% CI 0.51 to 1.49). Low dose compared to standard doseWeight gain was lower at very low dose compared to standard dose (1 RCT, n = 27, MD -2.70, 95% CI -5.38 to -0.02). Glucose level one hour after meal was also lower at very lose dose (1 RCT, n = 58, MD -1.60, 95% CI -2.90 to -0.30). Total cholesterol levels were higher at very low compared to standard dose (1 RCT, n = 58, n = 58, MD 1.00, 95% CI 0.20 to 1.80). Low dose compared to standard doseThere was evidence of fewer adverse effects, measured as lower TESS scores, in the low-dose group in the short term (2 RCTs, n = 266, MD -3.99, 95% CI -5.75 to -2.24); and in one study there was evidence that the incidence of lethargy (RR 0.77, 95% CI 0.60 to 0.97), hypersalivation (RR 0.70, 95% CI 0.57 to 0.84), dizziness (RR 0.56, 95% CI 0.39 to 0.81) and tachycardia (RR 0.57, 95% CI 0.45 to 0.71) was less at low dose compared to standard dose. AUTHORS' CONCLUSIONS: We found no evidence of effect on mental state between standard, low and very low dose regimes, but we did not identify any trials on high or very high doses of clozapine. BMI measurements were similar between groups in the short term, although weight gain was less at very low dose compared to standard dose in one study. There was limited evidence that the incidence of some adverse effects was greater at standard dose compared to lower dose regimes. We found very little useful data and the evidence available is generally of low or very low quality. More studies are needed to validate our findings and report on outcomes such as relapse, remission, social functioning, service utilisation, cost-effectiveness, satisfaction with care, and quality of life. There is a particular lack of medium- or long-term outcome data, and on dose regimes above the standard rate.

Antipsychotic utilization in the intensive care unit and in transitions of care.

PURPOSE: The objective of this study was to quantify the rate at which newly initiated antipsychotic therapy is continued on discharge from the intensive care unit (ICU) and describe risk factors for continuation post-ICU discharge. MATERIALS AND METHODS: This is a retrospective cohort study of all patients receiving an antipsychotic in the ICUs of a large academic medical center from January 1, 2005, to October 31, 2011. Medical record review was conducted to ascertain whether a patient was newly started on antipsychotic therapy and whether therapy was continued post-ICU discharge. RESULTS: A total of 39,248 ICU admissions over the 7-year period were evaluated. Of these, 4468 (11%) were exposed to antipsychotic therapy, of which 3119 (8%) were newly initiated. In the newly initiated cohort, 642 (21%) were continued on therapy on discharge from the hospital. Type of drug (use of quetiapine vs no use of quetiapine: odds ratio, 3.2; 95% confidence interval, 2.5-4.0; P < .0001 and use of olanzapine: odds ratio, 2.4, 95% confidence interval, 2.0-3.1; P ≤ .0001) was a significant risk factor for continuing antipsychotics on discharge despite adjustment for clinical factors. CONCLUSIONS: Antipsychotic use is common in the ICU setting, and a significant number of newly initiated patients have therapy continued upon discharge from the hospital.

Trastorno límite de la personalidad e ingesta de cuerpos extraños / Borderline personality disorder and foreign body ingestion

No disponible

[Amisulpride: a treatment option for psychotic disorders soon to be available in the Netherlands]. / Amisulpride: ook in Nederland een behandeloptie voor patiënten met een psychotische stoornis.

BACKGROUND: The antipsychotic drug amisulpride has not yet been officially approved for use in the Netherlands, although it is already available in other European countries , including Belgium, the UK and Germany. However, a fast-track procedure has recently been initiated so that amisulpride will soon become available in the Netherlands as well. AIM: To summarise the efficacy and side effects of amisulpride. METHOD: We discuss the evidence presented in the scientific literature. RESULTS: The scientific literature assures us that amisulpride is an effective antipsychotic drug with an acceptable range of side-effects. This means that there are two main advantages that ensue from the use of amisulpride: a patient's psychosis is more likely to go into remission and patients are less likely to stop taking the drug. CONCLUSION: The availability of amisulpride in the Netherlands will constitute a valuable addition to the pharmacotherapeutic options for treating psychotic disorders in our county.

[The relationship between the duration of drug use and the bipolar disorder patients' sociodemographic and clinical characteristics]. / Bipolar bozukluk hastalarinin ilaç kullanim sürelerinin sosyodemografik ve hastalik özellikleri ile iliskisi.

OBJECTIVE: The purpose of this study was to determine the duration of psychotropic drug use in the long-term follow-up of bipolar disorder (BD) patients. In addition, this study aimed to investigate their role in the daily clinical practice in association with patient sociodemographic and clinical characteristics. The overarching goal for this study was to produce results that enlighten the development of new treatment strategies. METHOD: Follow-up data acquired from the Psychiatry Department of Uludag University Faculty of Medicine was used to retrospectively evaluate 151 patients diagnosed with BD. Socio-demographic data of the patients and information regarding the disease and the drugs used were analyzed. RESULTS: Of the patients studied, 57.0% were female with a mean age of 41.5±12.8. The mean duration of follow-up was 1985.3±1933 [median 1291 (15-9135)] days; euthymic period accounted for 86.0% of this duration. Interestingly, incompliance with the treatment triggered the switch to mania and ineffective treatment triggered the switch to depression. Medication distribution was as follows: 95.4% of the patients received antipsychotic and mood stabilizer treatments, 3.3% received only mood stabilizer treatment, and 1.30% received only antipsychotic treatment. The major findings of this study was that many sociodemographic as well as clinical manifestations including, early onset (aged ≤18 years), unmarried, first episode of mania, those with disease not showing seasonal features, psychotic symptoms, history of hospitalization, and higher number of manic or hypomanic episodes resulted in increased patient prescribed antipsychotic drugs CONCLUSION: Our data suggests that antipsychotic drugs are being used more frequently and for longer durations in the treatment of BD.

Generic atypical antipsychotic drugs in Belgium: their influence and implications.

INTRODUCTION: Generic atypical antipsychotic drugs should be a focus of attention given their expenditure. However, there is a recognized need to tailor treatments. There were no specific measures in Belgium to enhance the prescribing of oral risperidone following generics in January 2008. Prescribing restrictions have remained for long-acting risperidone injections throughout. OBJECTIVE: Assess changes in risperidone utilization before and after oral generics were reimbursed, as well as the utilization and expenditure of the various risperidone preparations. METHOD: Principally a retrospective observational study and interrupted time series design. RESULTS: As expected, no increased utilization of oral risperidone after generics. Both originator and generic oral risperidone prescribed, with the originator reducing its price. Generic risperidone was 59% below prepatent loss prices by September 2012. CONCLUSION: Authorities cannot rely on a 'spill over' of learning from other disease areas to affect changes in physician prescribing habits. Specific measures are needed to encourage generic risperidone where appropriate. However, their influence will be limited by the complexity of the disease area.

Compliance to antipsychotic medication: a challenge for client, family and health care providers.

Compliance with anti-psychotic medications plays a significant role in managing clients with schizophrenia. It not only helps in controlling the symptoms, but also decreases the risk of relapses and ultimately improves quality of life (QoL) for the clients. However, compliance with anti-psychotic medication remains a challenge for the client, family and healthcare providers. Identification of these associated factors is vital to make appropriate plan to enhance medication compliance. In this paper, various factors are highlighted that are associated with medication compliance in clients with schizophrenia.

Urgencias en trastornos del movimiento que cursan con rigidez / Movement disorder emergencies accompanied by rigidity

Introducción. En el año 2002 se definieron las urgencias en trastornos del movimiento como cualquier trastorno neurológico, agudo o subagudo, en el que la presentación clínica está dominada por un trastorno del movimiento primario, y donde un fallo en el diagnóstico precoz puede resultar en una morbimortalidad importante. En este trabajo se revisarán aquellas urgencias en trastornos del movimiento que cursan con rigidez. En primer lugar las distonías agudas, siguiendo con el Síndrome Neuroléptico Maligno y por último una miscelánea de patologías. Objetivo. Revisar los avances más notorios publicados en la literatura científica en los últimos años en aquellas patologías que cursan con rigidez. Desarrollo. Se ha revisado la literatura de los últimos años y se presentan los avances más significativos en la patogenia, diagnóstico, y tratamiento, así como las principales perspectivas futuras en dichos campos (AU)

Introduction. In 2002 movement disorder emergencies were defined as any neurological disorder, either acute or subacute, in which the clinical presentation is dominated by a primary movement disorder, and where misdiagnosis in the early stages can result in important morbidity and mortality rates. This work reviews those movement disorder emergencies that are accompanied by rigidity. These are considered in the following order: first, acute dystonias, followed by neuroleptic malignant syndrome and, lastly, an assortment of other pathologies. Aims. The purpose of this study is to review the most significant advances in pathologies accompanied by rigidity that have recently been reported in the scientific literature. Development. The literature from the last few years was reviewed and we present the most significant advances in pathogenesis, diagnosis and treatment, as well as the main future perspectives in those fields (AU)