Psychotropics Under Siege

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Anasazi23

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We narrowly escaped yet another black-box warning on yet another commonly class of drugs prescribed by psychiatrists - antiepileptics.

From APA Headlines:
FDA panel votes against adding black-box warning to epilepsy drugs.
In continuing coverage from previous editions of Headlines, the Wall Street Journal (7/11, B6, Favole) reports, "A Food and Drug Administration (FDA) panel has recommended against adding the agency's toughest warnings to labels of epilepsy drugs, saying studies didn't show a high-enough risk for suicidal behavior to warrant such warnings." Fourteen of the FDA "panel members voted against adding the toughest warning, known as a black-box warning, while four voted in favor, and three abstained."
According to the AP (7/11, Perrone), some panel members said that "they worried the warning labels could inadvertently cause doctors and patients to abandon the treatments." Panel member Rochelle Caplan, M.D., a professor of psychiatry at University of California-Los Angeles, stated, "If we have good drugs that are working, we have to be very careful about scaring patients into not taking" these medications. And, "[p]hysician groups told panelists that patients experiencing seizures are already at risk for depression, making it difficult to tell whether drugs aggravate those problems." The AP quoted Jacqueline French, M.D., of the American Psychiatric Association, as asking, "Why put a black-box warning on, when you're not yet sure of the impact these drugs have?"
Bloomberg (7/11, Larkin) notes that drugmaker Pfizer also echoed the panel's concern, saying that "warnings may make patients reluctant to seek treatment they need." Christopher Wohlberg, M.D., Pfizer's medical team leader, told the panel that "[o]ver-warning has the potential to negatively impact patient care." And, psychiatrist Stefan Kruszewski, M.D., "who has reviewed cases for private insurance companies and the state of Pennsylvania," explained that some epilepsy drugs are used off-label "to treat psychiatric conditions, such as depression, anxiety, or dementia," or to control weight or manage headaches.
In a separate story, Bloomberg (7/11, Larkin, Waters) points out that the panel voted against the stronger warnings, but still "voted 20-0 that all epilepsy drugs increase the chance patients will consider suicide." Bloomberg adds that "[t]he panel also voted 18-3 that all 11 epilepsy medicines studied pose the suicide risk, and 15-5 that the danger also applies to 14 older treatments that weren't part of the review." HealthDay (7/10, Reinberg) and WebMD (7/10, Zwillich) also covered the story, as did USA Today's (7/10, Rubin) A Better Life blog, and ABC News (7/10, Cox) on its website.

I don't have the numbers in front of me, but I have to believe that there are many more psychotropics with prohibiting warnings and black boxes than any other system-class of drug. Another example of JCAHO-esque "everyone believing they can understand psychiatry?"

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I read an article about the same thing. Interesting.

The Church of Scientology claimed victory, implying they were connected with the black box warnings against antidepressants. While they claimed victory, I don't know exactly what they did to get those "victories". Did they lobby certain politicians?
 
I read an article about the same thing. Interesting.

The Church of Scientology claimed victory, implying they were connected with the black box warnings against antidepressants. While they claimed victory, I don't know exactly what they did to get those "victories". Did they lobby certain politicians?

The Scientologists have pre-formatted legislation that they introduce on a state by state basis once they can find a politician sympathetic to their cause to sponsor the bill.
 
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In clearwater, where many reside (very much near where I used to live), the style of scientologists is well known. Dig up dirt about the politicians and people of influence, blackmail them to make changes on issues according to their agenda. That might sound like the standard political group actively pushing their own agenda until you hear some of the ways they do it.

Worse story I heard was from my friend who worked as a senior staff at Kinkos. Told me the story when it happened. He had come to work and the entire computer area was closed. The manager was inside with the FBI going through a certain computer. They called my friend and explained that they need the computer area. Later the story from the manager is that a scientologist had been purchasing time on the computer in Kinkos, using it (that way it doesnt get traced back to their own computer) to hack into someone's computer (they didnt mention the name) and blackmailing them with the information. The FBI was trying to find out clues about who this scientologist was. My friend didn't know the outcome, but they eventually took the computer.
 
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From the American Psychiatric Association
FDA COMMITTEE VOTES AGAINST BLACK BOX WARNING ON EPILEPSY MEDICATIONS
As you may have heard, late last week advisers to the Food and Drug Administration voted 14-4 against adding a "black box" warning about the risk of suicide to all anti-seizure medications. The panel expressed concern that the risk of patients changing medications or discontinuing treatment was too high.
Darrel Regier, M.D., MPH, testified on behalf of the APA. He presented concerns about the adequacy of the FDA statistical findings on which the recommendation for a black box warning was based, and the potential impact on clinical practice of reducing the use of mood stabilizers. He also expressed the potential risk of the dilution of the impact of black box warnings when they are applied on the basis of minimal evidence.
Instead of a label warning, panelists suggested that medication guides be distributed with information about potential suicide risks.
The FDA is set to make a decision soon.
More from fearless leader, the FDA.
 
I'm just getting started in the clinical side of medicine, but I worked for the NIH for a while and I wonder if this article made anyone else curious for more detail.

If I'm not mistaken, the most popular antiepileptic is Neurontin, which is a Pfizer product. I don't know much about research in the field of psychiatry, but with the article quoting so many Pfizer reps and Pfizer-affiliated physicians, is it possible Pfizer is using influence to stall investigation of drugs that are potentially worth a suicide risk label?

I'm not that Skee Lo guy -- I think psychiatry is fascinating; I'll be pursuing residency in either psychiatry or emergency medicine. But whenever I see a drugmaker so closely in-tune with the FDA's position, the subversive in me wonders if foulplay isn't afoot.
 
That might sound like the standard political group actively pushing their own agenda until you hear some of the ways they do it.

Per the Time Article that opened the floodgates onto informing the public as to how viscious they are, that's how they operate. They try to ruin people that go against them or bog them down in a lawsuit they can't afford to keep up. When Scientology loses the case, they just appeal & do every stall tactic in the book to put their opponent into fiscal ruin. The Church has been known to take photos & people who just happen to show up near their facilities on more than one occasion, to investigate who these people are. The author of that Time article claimed several similar things happened to him such as someone illegally obtaining his credit report.

is it possible Pfizer is using influence to stall investigation of drugs that are potentially worth a suicide risk label?

I don't know but I wouldn't be surprised. Pfizer has already been found to be breaking the law in terms of advertising over Neurontin.
http://www.npr.org/templates/story/story.php?storyId=1895708
I had heard several of the accusations against Pfizer.

However Neurontin is now available as a generic (Gabapentin) and when generics are available the parent company tends to have a "whatever" attitude with them.
 
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More...
http://pn.psychiatryonline.org/cgi/content/full/43/14/1

basically, black boxes are going on first generation antipsychotics as well, in addition to the atypicals.

They claim that the patients have a hazard mortality ratio 1.47 compared to SGAs, and that patients were matched for clinial status. I didn't read the original study, but it'd be curious to know the

As usual, the FDA provides no reasonable alternative. This is only fodder for incompetent practitioners to make non-decisions, and helps trial lawyers, which is always a clinically sound thing to do.

They also imply astonishment at the fact that the FGAs were actually more dangerous than the SGAs. Anyone who knows any pharmacology at all was not surprised by this. They apparently were.

But don't even think about worrying about lawsuits, since,
...No antipsychotics have been approved for treating psychosis or agitation in elderly patients with dementia. In fact, no drug has been approved for these symptoms. Laughren also emphasized that the black-box warning is not a contraindication, and clinicians still have the option of using these drugs for dementia patients at their discretion.

I wonder why the FDA feels as though they have no other fish to fry than those guppies in the psychiatry frying pan. Psychiatrists are often the only, or last resort doctor to see these patients, their families, and try to bring some semblance of sanity to a ward that would otherwise be uninhabitable for all other patients there, and the visiting families. For God's sake, give it a rest with the black boxes, FDA.
 
From APA Headlines again:

Article examines why one class of medications received black-box warning and another did not.
The Los Angeles Times (8/18, Ravn) reported that fluoroquinolones and antiepileptic medications "were candidates for a 'black-box' warning." Yet, while "one was hit with this safety advisory, the other may have escaped." In July, the FDA "decided to order black-box warnings on the professional labels." Paul Seligman, M.D., M.P.H., of the FDA, said that the risk from fluoroquinolones (tendon problems) "has been around for a long time, and doctors know about it." But, Seligman added, "We needed to get patients more aware and engaged." Antiepileptic medications, however, "were associated with an increased risk of suicidality." An FDA advisory panel recommended medication guides to patients taking the medication long-term, but not a black-box warning. According to Larry Goldstein, M.D., acting chairman of the antiepileptic medication advisory committee, the warning "could make people so afraid of using the medication that patients who should be treated wouldn't be treated." A study this year found that when the "FDA required the warning to be added to" labels of antidepressants "in Oct. 2004,...antidepressant use by youths fell about 10 percent a year."

So does this mean that when lots of people know about this questionably existant "finding", they'll take the black box away? Somehow I don't think so.
 
Today I was walking down the street in Manhattan, on my way to Gamestop to trade in a bunch of old stuff, when a guy standing on the corner was handing out flyers. This is commonplace in NYC, and I almost universally don't take them. Something compelled me to grab this one, however, and I did.

Lo and behold, it read something like (from memory since I ripped it up):

Did you know that medicines can stay in your body long after you've taken them? Did you know that 80 something percent of American's think we're "overmedicated," and that mind-altering drugs can make you feel cloudy, blah, blah?

L. Ron Hubbard believed blah blah blah. You can be free of these effects and find meaning in both your physical and spiritual life. Blah, blah, blah.

I had a small urge to go talk to this guy and run him gently through the ringer on his "beliefs." But, I wanted the God of War PSP and was on a time constraint....so I continued on.

Just thought I'd share that.
 
Today I was walking down the street in Manhattan, on my way to Gamestop to trade in a bunch of old stuff, when a guy standing on the corner was handing out flyers. This is commonplace in NYC, and I almost universally don't take them. Something compelled me to grab this one, however, and I did.
...
I had a small urge to go talk to this guy and run him gently through the ringer on his "beliefs." But, I wanted the God of War PSP and was on a time constraint....so I continued on.

Just thought I'd share that.

Thus speaketh the Holy DSM-IV-TR:
Substance [Video Game] Dependence:

criterion (6): important social, occupational, or recreational activites are given up or reduced because of substance [video game] use.


So basically, you neglected your profession in order to obtain your drug? ;)
 
As usual, the FDA provides no reasonable alternative. This is only fodder for incompetent practitioners to make non-decisions, and helps trial lawyers, which is always a clinically sound thing to do.

I remember some attending mentioned that to defend yourself against the BB warning, get the delirious/demented patient's consent before you give the antipsychotic.

OK-so you got a dementia patient who's ripping IV's, peeing in their bed & won't respond logically to any redirection or questions, and I'm going to get consent from this patient?

What I do is when I had a consult for this, I'd document something to the effect of, "despite the BB warning against atypical antipsychotics, given the immediate danger this patient presents to others & himself & that the risk factor in the use of antipsychotics is lower, I reccomend (insert antipsychotic here)."

When it comes to consults, geez, you might as well carry a stamp that says the above & just stamp it on most of your dementia/delirium consults.
 
I remember some attending mentioned that to defend yourself against the BB warning, get the delirious/demented patient's consent before you give the antipsychotic.

OK-so you got a dementia patient who's ripping IV's, peeing in their bed & won't respond logically to any redirection or questions, and I'm going to get consent from this patient?

What I do is when I had a consult for this, I'd document something to the effect of, "despite the BB warning against atypical antipsychotics, given the immediate danger this patient presents to others & himself & that the risk factor in the use of antipsychotics is lower, I reccomend (insert antipsychotic here)."

When it comes to consults, geez, you might as well carry a stamp that says the above & just stamp it on most of your dementia/delirium consults.


That's the nice thing about having an electronic medical record--you can just create it as a "smart text" or shortcut and zip it in with a couple of keystrokes.
 
I remember some attending mentioned that to defend yourself against the BB warning, get the delirious/demented patient's consent before you give the antipsychotic.

OK-so you got a dementia patient who's ripping IV's, peeing in their bed & won't respond logically to any redirection or questions, and I'm going to get consent from this patient?

What I do is when I had a consult for this, I'd document something to the effect of, "despite the BB warning against atypical antipsychotics, given the immediate danger this patient presents to others & himself & that the risk factor in the use of antipsychotics is lower, I reccomend (insert antipsychotic here)."

When it comes to consults, geez, you might as well carry a stamp that says the above & just stamp it on most of your dementia/delirium consults.

Right, I love my canned text that includes the phrase "risk/benefit calculus".
 
From APA Headlines:

FDA unveils list of medications with potential safety problems.
The Washington Post (9/6, A2, Brown) reported, "The Food and Drug Administration (FDA) will begin posting every three months a list of" medications "whose safety is under investigation because of complaints brought to the agency's attention by" pharmaceutical "companies, physicians, and patients." On the list, the medication "and the nature of the 'adverse events'" will be named, but the agency "will not describe their seriousness, or the number of complaints received." The Post also pointed out that "being on the list does not mean the" medication "is unsafe, only that the FDA is looking into that possibility."
The Wall Street Journal (9/6, A4, Favole, Wang) added that "the list includes a wide array of" medications, including the antidepressant Cymbalta (duloxetine). The agency "has already sent out warnings about a handful of the" medications "on the list. ... But, there appear to be new ones, too." Now, the FDA plans to notify "companies whose" medications "appeared on the list prior to it being made public." And, while pharmaceutical companies said that "they support the FDA's additional efforts to be transparent about" medication safety, they "expressed concern that the information was being communicated to patients without context, and wondered about what patients might do with the information."
The AP (9/6, Alonso-Zaldivar) echoed that sentiment, noting that "consumer advocates called the listing a positive step, but said it needs to be fleshed out." Thomas J. Moore, of the Institute for Safe Medication Practices, said that the list "needs to have much more detail if it's to have significant safety value."
"This information is being posted as part of the 2007 Food and Drug Administration Amendments Act," according to HealthDay (9/5, Reinberg). "Under the act, the agency must post quarterly information on potential" medication "risks, based on the agency's review of adverse-event reports submitted by doctors." The list will only contain medications from the "issues identified in the adverse-event reporting system." But, it "will not include all the" medications "the FDA is currently reviewing for safety problems," said Gerald Dal Pan, M.D., M.P.H., director of the FDA's Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research. The first list, which was released last week, only includes" medications "from the first quarter of this year. Medications "under investigation before 2008, or after March, aren't included."
The Los Angeles Times's (9/6, Roan) Booster Shots blog quoted Janet Woodcock, M.D., of the FDA's Center for Drug Evaluation and Research, as saying, "My message to patients is this: Don't stop taking your medicine. If your doctor has prescribed a" medication "that appears on this list, you should continue taking it, unless your doctor advises you differently."
Modern Healthcare (9/6, DerGurahian), UPI (9/6), AHN (9/6, Sharma), and WebMD (9/5, DeNoon) also covered the story. The AP (9/6) also published the complete list of medications released by the FDA, including "Seroquel (quetiapine), for bipolar disorder."

Any bets on which class will top the list?
 
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