NY Times Article - Antipsychotic Medications
Started by owlegrad
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nothing surprising
in my experience, with FP and neuro rotations, they werent so hot on these new psych meds and what not and always tried other alternatives first...but the only one they used consistently was low dose seroquel in the elder population, works so well and they all loved using it
in fact, the neuro guys i was with actually have a letter they make the pt or pt guardian sign that they acknowledge the cardiovascular/sugar risks whenever they start some1 on any of these drugs....prolly wont protect them from a lawsuit 100%, but at least it makes the pt aware about potential side effects
in my experience, with FP and neuro rotations, they werent so hot on these new psych meds and what not and always tried other alternatives first...but the only one they used consistently was low dose seroquel in the elder population, works so well and they all loved using it
in fact, the neuro guys i was with actually have a letter they make the pt or pt guardian sign that they acknowledge the cardiovascular/sugar risks whenever they start some1 on any of these drugs....prolly wont protect them from a lawsuit 100%, but at least it makes the pt aware about potential side effects
I just finished a psych rotation and was taught (by the attending) to never use Seroquel in the elderly. He was also very displeased with the number of people prescribing Seroquel for sleep (thought it was inappropriate).
The facility I rotated at (acute care state psych hospital) has a new metabolic syndrome monitoring program for atypicals. I helped with the implementation. It was labor intensive, but needed. The risks are real.
Of course, that doesn't touch on the inappropriate use of atypicals (for off label or in patients who don't clearly need them). Most of our patients at the psych hospital CLEARLY needed them, so we monitored the side effects. In pts who are less clearly appropriate for atypicals, do the benefits of using them outweigh the risks? I think that's what the article is driving at, and it's a good question.
The facility I rotated at (acute care state psych hospital) has a new metabolic syndrome monitoring program for atypicals. I helped with the implementation. It was labor intensive, but needed. The risks are real.
Of course, that doesn't touch on the inappropriate use of atypicals (for off label or in patients who don't clearly need them). Most of our patients at the psych hospital CLEARLY needed them, so we monitored the side effects. In pts who are less clearly appropriate for atypicals, do the benefits of using them outweigh the risks? I think that's what the article is driving at, and it's a good question.
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its funny, the neuro guys would always get letter from insurance company rph telling them about latest studies and how alternatives performed compared to seroquel
but like i said, these guys LOVE it, and in their clinical experience, have not had problems with it
but regardless, i think it is good to have the debate and nice to see nytimes picking up on the issue
If we had to use an anti-psychotic in an elderly patient, we usually chose risperidone. That was the case on my VA geriatric rotation as well. One of my elderly patients at the psych hospital was admitted with a very low BMI. For her, we chose olanzapine because we were hoping she'd gain weight (she did).
during my discussions, i was told something along the lines:
being able to control hallucinations and other psych symptoms is the difference between the family being able to take care of the pt at home, or the pt going to a nursing home or some assisted care living place...so the family is not concerned with increased sugar or bp, etc., so long as they are able to continue to provide care at home for the pt.
and then theyd put em on low dose seroquel (50 or so).
I dont have a problem with their way of operating, they are good docs and taught me pretty much everything I know from a clinical standpoint....my problem, or rather my questioning, comes to these psych docs who completely snow the pt putting them on like 600+mg seroquel a day + other psych drugs....seems like overkill!!!👎
being able to control hallucinations and other psych symptoms is the difference between the family being able to take care of the pt at home, or the pt going to a nursing home or some assisted care living place...so the family is not concerned with increased sugar or bp, etc., so long as they are able to continue to provide care at home for the pt.
and then theyd put em on low dose seroquel (50 or so).
I dont have a problem with their way of operating, they are good docs and taught me pretty much everything I know from a clinical standpoint....my problem, or rather my questioning, comes to these psych docs who completely snow the pt putting them on like 600+mg seroquel a day + other psych drugs....seems like overkill!!!👎
When i think of Seroquel I think of a copycat, of Clozapine. Yeh Seroquel blows.
Why not just use Depakote? You get the weight gain and the calming effect.
In nursing homes, I heard that there can be investigations if the elderly are being "sedated" with benzos so docs have to use something else.
Also, what about in patients with dementia? Isn't there a warning against using risperidone? What would you select as an alternate?
EDIT: btw I didn't get to read the entire article so maybe I missed something along the way
In nursing homes, I heard that there can be investigations if the elderly are being "sedated" with benzos so docs have to use something else.
Also, what about in patients with dementia? Isn't there a warning against using risperidone? What would you select as an alternate?
EDIT: btw I didn't get to read the entire article so maybe I missed something along the way
There is a warning about ALL atypicals in geriatric patients with dementia, but it is not an absolute contraindication. It's a risk vs. benefit decision.
At the VA we use Depakote for behavioral symptoms in patients with dementia, usually after we've already tried Aricept and Namenda. We had a few patients who could not tolerate Depakote for whatever reason, and in those cases we went to risperidone. Unfortunately there are no easy answers in psych and what works for one patient may not for another.
Remember, the MOA of Depakote and the anti-psychotics is not the same, so you can't just say "use Depakote instead." For my little underweight patient at the state psych hospital, she was having hallucinations and delusions. She needed an anti-psychotic to stabilize her, but it was not intended to be part of her long term treatment.
RE: nursing homes. It's not just benzodiazepine use that is scrutinized. It's psychotropics in general. The use of any type of chemical restraint must be appropriate. I've done 90 day reviews for nursing home patients and ICF/MR patients and we looked at benzos, Depakote (for all indications other than seizures), anti-psychotics, etc. Anything sedating. You can't just sedate a patient to deal with behavioral problems. At least not first line.
I see. Thanks for the clarification. This info is extremely helpful as I embark on my journey through pharm school. I love SDN!
I have been told by different pharmacists that aricept doesn't really work. Then others tell me it slows the progression of the disease and is very helpful. Who should I believe?
I see. Thanks for the clarification. This info is extremely helpful as I embark on my journey through pharm school. I love SDN!
I have been told by different pharmacists that aricept doesn't really work. Then others tell me it slows the progression of the disease and is very helpful. Who should I believe?
I don't think you can say aricept "slows the progression of the disease"... it is simply an acetylcholinesterase inhibitor that happens to have a moderately high affinity for the achE in the CNS that are destroyed by the plaques and tangles. I don't think there is any definitive evidence (please correct me if i'm wrong) that aricept does anything but slightly improve the symptoms in these patients by causing more stimulation of the acetyl-choline receptors in the HC and pre-frontal cortex.
I didn't say that. Someone else did. Which is why I am asking if it works. So, does it?
when I say "you" I mean people in general. I'd say it is entirely dependent on the person and the types of synaptic connections present and what specific neurons/groups of neurons are in the process of being destroyed, attempting repairs, and being in the presence of immune cells, etc (overall the environment). It has definitely been shown to improve the symptoms in certain patients but minimally effective in others. The drug is doing it's job regardless (binding AChE) but it's physiological response is dependent on the factors above.
My understanding of Aricept (and the other drugs like it) is that it does slow disease progression moderately but does not restore any functioning already lost. Alzheimer's is characterized by cholinergic deficiency in the brain. This contributes to the cognitive deficits. Aricept and company just increase the amount of ACh available for transmission. The way the attending explained it to me was something like "patients on Aricept do not decline as quickly, but they do continue to decline as AZD is progressive and fatal. You're buying yourself six months (or so)."
I think the "Aricept doesn't work" belief comes from people who are expecting too much from the drug. It's NOT going to make Granny less forgetful. It's NOT going to make Pappy "like himself again." It's difficult to gauge how well it works because the outcome ("slowed decline") is hard to measure. How do you know how quickly the patient would have declined without the drug? It's also expensive and people want to see results for their $$$.
Just my opinion.
I think the "Aricept doesn't work" belief comes from people who are expecting too much from the drug. It's NOT going to make Granny less forgetful. It's NOT going to make Pappy "like himself again." It's difficult to gauge how well it works because the outcome ("slowed decline") is hard to measure. How do you know how quickly the patient would have declined without the drug? It's also expensive and people want to see results for their $$$.
Just my opinion.
It kinda irritates me when "off label" use is purported to be something evil. What about delirium in the hospital? Not that I'm the first one to jump to Vitamin H, or it's newer sibling Seroquel, but I think it's a legitimate off-label use. Other than that, drug companies are bad, blah blah blah. Not much of a surprise there, hence why we do journal clubs and look at postmarketing data.
BTW, speaking of vitamin H, did all y'all know that IV haldol is not FDA approved? zomg what now?!
BTW, speaking of vitamin H, did all y'all know that IV haldol is not FDA approved? zomg what now?!
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