Although antipsychotic prescribing in elderly patients using polypharmacy has not been studied in well-designed clinical trials and meta-analyses, there is an urgent need to monitor prescribing practice in this population. One of the possible approaches to optimize pharmacotherapy may be the involvement of clinical pharmacists (CPs). The aim of this research was to examine whether the involvement of a CP can improve treatment guidelines adherence and change the total number of medications per patient in older patients who are treated with excessive polypharmacy that includes antipsychotics.
This cohort retrospective study included older patients (65 years or older) treated with at least one antipsychotic and excessive polypharmacy (10 or more medications concurrently) between 2012 and 2014 in primary care. The main outcome measures were antipsychotic treatment guidelines’ adherence and the total number of medications per patient after the CP’s interventions. Only interventions including antipsychotics were studied in detail (i.e., discontinuation, switching, initiation, dose adjustment, change of another medication because of a drug-related problem). Data on diagnoses, patient pharmacotherapy and the CP’s interventions were obtained from clinical records and medical reviews. Age and acceptance of the CP’s interventions were used as predictive factors for antipsychotic treatment guidelines’ adherence.
Forty-nine patients were included. The CP suggested 21 different interventions of which nine (42.8%) were accepted by the general practitioners. The number of medications that patients received decreased after the CP’s interventions (N of medications before: 15.4; N of medications after: 12.0, p < 0.05). The acceptance of the CP’s recommendations, but not age, improved antipsychotic treatment guidelines’ adherence (p = 0.041).
These results show that a collaborative care approach including a CP in primary care significantly improved the adherence to treatment guidelines. The results also support the implementation of this service in the Slovenian healthcare system, although more studies are needed.
Uvod: Zdravljenje z atipičnimi antipsihotiki predstavlja najpomembnejši način zdravljenja bolnikov z akutno shizofrenijoin predstavlja veliki strošek. V Sloveniji nam primanjkuje raziskav stroškovne učinkovitosti atipičnih antipsihotikov,ki jih lahko uporabimo v klinični praksi.
Namen: Osnovni namen raziskave je bil primerjava stroškov in učinkovitosti petih atipičnih antipsihotikov z največjimtržnim deležem v letu 2011 v Sloveniji. V raziskavo smo vključili aripiprazol, kvetiapin, paliperidon, risperidon in olanzapin.
Metode: Ciljna populacija v raziskavi so bili slovenski bolniki z akutno shizofrenijo. Vsak izmed petih antipsihotikovpredstavlja glavno vejo odločitvenega drevesa. Terapevtska učinkovitost je bila določena kot verjetnost letne remisije.Ceno dnevnega zdravljenja s posameznim zdravilom smo pridobili iz podatkov tržnega deleža in prometa v letu2011, stroške mentalnega zdravstvenega varstva v Sloveniji pa smo pridobili iz podatkov Zavoda za zdravstvenozavarovanje Republike Slovenije. Raziskava je bila zasnovana z vidika plačnika, tj. Zavoda za zdravstvenozavarovanje Republike Slovenije.
Rezultati: Zdravljenje z risperidonom je najcenejše, najučinkovitejše pa z olanzapinom. Strategija zdravljenja zrisperidonom ima najmanjši kvocient med stroški in učinkovitostjo. Strategije zdravljenja z aripiprazolom, s kvetiapinomin paliperidonom so prevladujoče. Cene letnega zdravljenja so: 6.812 EUR za risperidon, 7.509 EUR za kvetiapin,7.295 EUR za olanzapin, 8.229 EUR za aripiprazol in 8.044 EUR za paliperidon. Učinkovitosti, podane v deležuletne remisije, so: 0,605 - kvetiapin, 0,603 - aripiprazol, 0,671 - risperidon, 0,723 - olanzapin in 0,712 - paliperidon.
Sklep: Rezultati študije kažejo, da je najbolj stroškovno učinkovito zdravljenje akutneshizofrenije z risperidonom in olanzapinom
There is almost no data on antidepressant prescribing in older adults treated with polypharmacy, although this population represents approximately 50% of older patients. These patients are frequently excluded from double-blind randomized controlled trials, meta-analyses and existing treatment guidelines. The main aim of this paper was to identify data on antidepressant prescribing in depressed older adults on polypharmacy using a systematic review.
Randomized controlled clinical trials (RCTs) and other clinical trials in Medline/PubMed without language limitation (-2017) were searched to identify those with older depressed patients on polypharmacy. Only elderly patients (>65 years as mean) were included. Only approved antidepressants were included.
The systematic search identified 26 different clinical trials, although only one clinical open label trial with sertraline met the final inclusion criteria. This sertraline trial indicated the absence of clinically important drug-drug interactions and confirmed the effectiveness and safety of sertraline in routine clinical practice. Heterogeneity in this trial was high in almost all the categories except attrition and reporting bias.
Sertraline has the highest evidence level in older adults with depression on polypharmacy. According to the results of this review and due to a low number of appropriate trials, a basic understanding of psychopharmacology is the possible approach to avoid serious problematic drug combinations in these patients. Newer RCTs are also urgently needed. This is the first systematic review including patients treated with polypharmacy, and therefore, its results are important in the field of evidence-based medicine.