58. Limitations- What We Don’t Know Efficacy of non-Clozapine SGA Polypharmacy in treatment resistant psychosis Efficacy of Clozapine polypharmacy in non-treatment resistant psychosis
59. Aripiprazole augmentation of Risperidone or Quetiapine Correll, Kane, Goff et.al. June , 2008 Poster 16 week, double blind, placebo controlled RTC 323 patients on risperidone or quetiapine given aripiprazole or placebo No improvement in symptoms with SGA polypharmacy Mixed changes in side effects
60.
61. Published Practice GuidelinesRegarding Antipsychotic Polypharmacy Published Guide lines include American Psychiatric Association Expert Consensus Guideline Series Texas Medication Algorithmns PORT All recommend use of more than one AP only: After multiple trials of monotherapy After trial of clozapine
62. Justifications for Antipsychotic Polypharmacy Clozapine Augmentation A History of 3 or more failed Trials of monotherapy Recommended Plan to taper to monotherapy
63. §483.450(e) Standard: Drug Usage (e)(1) The facility must not use drugs in doses that interfere with the individual client’s daily living activities. (e)(2) Drugs used for control of inappropriate behavior must be approved by the interdisciplinary team andbe used only as an integral part of the client’s individual program plan that is directed specifically towards the reduction of and eventual elimination of the behaviors for which the drugs are employed. http://www.cms.gov/manuals/downloads/som107ap_j_intermcare.pdf accessed 4.09.10
64. §483.450(e) Standard: Drug Usage (e)(3) Drugs used for control of inappropriate behavior must not be used until it can be justified that the harmful effects of the behavior clearly outweigh the potentially harmful effects of the drugs. (e) (4)(i) Drugs used for control of inappropriate behavior must bemonitored closely,in conjunction with the physician and the drug regimen review requirementfor desired responses and adverse consequences by facility staff; and http://www.cms.gov/manuals/downloads/som107ap_j_intermcare.pdf accessed 4.09.10
65. §483.450(e) Standard: Drug Usage (e)(4)(ii) Gradually withdrawn at least annually in a carefully monitored program conducted in conjunction with the interdisciplinary team, unless clinical evidence justifies that this is contraindicated http://www.cms.gov/manuals/downloads/som107ap_j_intermcare.pdf accessed 4.09.10
66. Spectrum of AP Side Effects NMS EPS Prolactin WBC Weight Gain ANTIPSYCHOTIC AGENTS Diabetes/DKA Sedation Lipids Seizures Anticholinergic Orthostasis NMS = Neuroleptic Malignant Syndrome
67. Relative Risk of Side Effects Among Agents Professional Resources & Business Development +++ substantial risk, ++ moderate risk, + mild risk, +/- minimal risk or insufficient data Mueser KT, Jeste DV. in Clinical Handbook of Schizophrenia, 2008, Fuller M, Sajatovic M, in Psychotropic Drug Information Handbook 2009, Drug PIs
68. Meaningful Medication Tapers Polypharmacy – 2 or more in same class 25% dose reduction per month Completely off in 6 – 9 months Monotherapy – only one of that class 10% dose reduction per month Completely off in 12 – 18 months