What Clinicians Need to Know About Antipsychotic Pharmacy Lauren - PowerPoint PPT Presentation

What Clinicians Need to Know About Antipsychotic Pharmacy Lauren Hanna, M.D. and Delbert Robinson, M.D. Northwell Health National Council for Behavioral Health Montefiore Medical Center Northwell Health New York State Office of Mental Health Netsmart Technologies

Objectives • In this presentation, we will review the most common rationales for antipsychotic polypharmacy. • We will identify which of these rationales warrant antipsychotic polypharmacy and which do not. • We will review an algorithm for antipsychotic treatment strategies.

Outline • Common Rationales for Antipsychotic Polypharmacy • Is Antipsychotic Polypharmacy Ever Warranted? • Antipsychotic Treatment Algorithm

Poll What is your primary role in your organization? A. Administrator B. Prescribing clinician C. Non-prescribing clinician D. Researcher E. Other

Common Rationales for Antipsychotic Polypharmacy

Case One • An 18-year-old male with no prior psychiatric history and no significant medical or substance history is diagnosed with first episode psychosis after experiencing symptoms of auditory hallucinations and referential delusions daily for the past month. He is prescribed risperidone but has no insight into his illness and only takes the medication once or twice a week. After several weeks of this pattern, there is no noted improvement in his symptoms.

Poll What is the most likely reason the antipsychotic is ineffective for treating the psychosis? A. This particular antipsychotic is not effective for this particular patient. B. This patient is likely a non-responder to all antipsychotic medications. C. This patient was not treated with an adequate dose of antipsychotic medication to accurately judge its effectiveness. D. This patient was not treated for a sufficient length of time to accurately judge the antipsychotic medication’s effectiveness. E. This patient was not taking the antipsychotic consistently enough to accurately judge the medication’s effectiveness.

Poor Treatment Response to Monotherapy Due to Non-Adherence • A common cause of poor treatment response is poor medication adherence. • The goal should be at least 80% adherence. • Antipsychotic polypharmacy is not a valid treatment strategy in cases of poor response due to sub-optimal adherence. • A long-acting injectable antipsychotic is the preferred strategy in this case.

Non-adherence in the treatment of chronic disorders • In developed countries, about 50% of patients with chronic diseases adhere to long-term therapy 1 • 33 – 69% of all medication-related hospital admissions in the US are due to poor medication adherence 2 • One-third of all prescriptions are never filled 3 • >50% of filled prescriptions are associated with incorrect administration (not taken as prescribed) 3 1. WHO Report 2003; Adherence to long-term therapies: evidence for action; 2. Osterberg, L and Blaschke, T. N Engl J Med 2005;353:487 – 97; 3. Peterson AM, et al. Am J Health Syst Pharm 2003;60:657 – 65. 9

Case Two • A 20-year-old woman with history of newly diagnosed schizophrenia is prescribed aripiprazole during her first inpatient admission. The dose is quickly maximized to 30mg over 1 weeks time and she takes it as prescribed. After 2 weeks of treatment, her positive symptoms of psychosis have improved somewhat, but her treatment team is considering adding another antipsychotic as some symptoms persist.

Poll What is the most likely reason the antipsychotic is ineffective for treating the psychosis? A. This particular antipsychotic is not effective for this particular patient. B. This patient is likely a non-responder to all antipsychotic medications. C. This patient was not treated with an adequate dose of antipsychotic medication to accurately judge its effectiveness. D. This patient was not treated for a sufficient length of time to accurately judge the antipsychotic medication’s effectiveness. E. This patient was not taking the antipsychotic consistently enough to accurately judge the medication’s effectiveness.

Poor Treatment Response to Monotherapy Due to Inadequate Trial Length • A common cause of poor treatment response is inadequate trial length. • In general, 6 week duration is the standard appropriate acute trial length. • In first episode psychosis, acute trials of up to 16 weeks are appropriate.

Case Three • A 45-year-old man with history of multiple episode schizophrenia and good prior treatment response to olanzapine is admitted for decompensation of symptoms after his insurance changed a few months ago and he was not able to continue with his most recent psychiatrist. He is seen in an Emergency Department and started on olanzapine 5mg and referred to an outpatient clinic that takes his insurance. It has taken about 3 months to see the psychiatrist there due to a long waiting list. Once he meets the psychiatrist there, despite taking the olanzapine 5mg daily (getting refills from Emergency Departments in the interim) he is still significantly symptomatic.

Poll What is the most likely reason the antipsychotic is ineffective for treating the psychosis? A. This particular antipsychotic is not effective for this particular patient. B. This patient is likely a non-responder to all antipsychotic medications. C. This patient was not treated with an adequate dose of antipsychotic medication to accurately judge its effectiveness. D. This patient was not treated for a sufficient length of time to accurately judge the antipsychotic medication’s effectiveness. E. This patient was not taking the antipsychotic consistently enough to accurately judge the medication’s effectiveness.

Poor Treatment Response to Monotherapy Due to Inadequate Dose • A common cause of poor treatment response is inadequate dose. • Doses should be maximized as trials approach 6 weeks. • Doses are generally lower in first episode psychosis, but should be maximized as trials approach 16 weeks.

Case Four • A 30-year-old woman with a long duration of untreated psychosis is started on an antipsychotic medication after psychiatry is consulted while she is hospitalized for a minor medical procedure. She is started on risperidone and referred to outpatient treatment. She agrees to a long-acting injectable antipsychotic of paliperidone and thought started on the recommended maintenance dose, is increased over the next 4 months due to non-response of her symptoms to treatment.

Poll What is the most likely reason the antipsychotic is ineffective for treating the psychosis? A. This particular antipsychotic is not effective for this particular patient. B. This patient is likely a non-responder to all antipsychotic medications. C. This patient was not treated with an adequate dose of antipsychotic medication to accurately judge its effectiveness. D. This patient was not treated for a sufficient length of time to accurately judge the antipsychotic medication’s effectiveness. E. This patient was not taking the antipsychotic consistently enough to accurately judge the medication’s effectiveness.

Poor Treatment Response to Monotherapy Despite Adequate Trial Length and Adherence What about two antipsychotics instead of one for persistent symptoms?

PORT guidelines from 2009

Poor Treatment Response to Monotherapy Despite Adequate Trial Length and Adherence After one failed antipsychotic trial of adequate length and duration… … switching to a second antipsychotic agent is recommended.

Case Five • After the 30-year-old woman from the last vignette was switched from paliperidone LAI to olanzapine and transitioned to its LAI formulation, her symptoms still do not respond despite another 2 months on the new medication.

Poll What is the most likely reason the antipsychotic is ineffective for treating the psychosis? A. This particular antipsychotic is not effective for this particular patient. B. This patient is likely a non-responder to all antipsychotic medications. C. This patient was not treated with an adequate dose of antipsychotic medication to accurately judge its effectiveness. D. This patient was not treated for a sufficient length of time to accurately judge the antipsychotic medication’s effectiveness. E. This patient was not taking the antipsychotic consistently enough to accurately judge the medication’s effectiveness.

After 2 failed antipsychotic trials… … a trial of clozapine is recommended for patients with history of suboptimal response to trials of 2 antipsychotic agents (assuming adequate dose, duration, and adherence)

Poll Do you utilize clozapine at your clinic? A. Yes B. No C. Thinking about it

What is an adequate dose and duration of f a clozapine trial? • 30% of patients will respond by 6 weeks • 20% of patients will respond by 3 months • 10-20% of patients will respond by 6 months • Some patients will take more than 6 months to respond • A trial of clozapine monotherapy of 6-12 months is reasonable

Consider augmentation with ECT after suboptimal response at adequate plasma level (450ng/mL) for adequate duration.

Is antipsychotic polypharmacy ever warranted?

Cross Tit itration fr from One Antipsychotic to Another • Two antipsychotics may be temporarily prescribed at the same time when changing from one antipsychotic to another due to poor response or inability to tolerate side effect.