Depots Improving patient care?

Transcription

1 Depots Improving patient care? Caroline Parker Consultant Pharmacist NAPICU Conference 9 th September 2010

2 Depots Coercion Paternalistic Degrading Standard treatment Necessary Old fashioned Forced Easier to remember Ensures compliance EPS Convenient No choice

3 Depots

4 Depot - definition Long-acting injection Doesn t necessarily mean antipsychotics e.g. Depo-Provera (contraceptive) Depo-Medrone (methylprednisolone = steroid) Doesn t necessarily mean oily Usually IM Not implants

5 Trade Name Generic Name Formulation Administration (IM) Since Clopixol Zuclopentixol decanoate Oily Gluteal, every 1-4 weeks 1978 Depixol Flupentixol decanoate Oily Gluteal, every 1-4 weeks 1972 Haldol Haloperidol decanoate Oily Gluteal, every 4 weeks 1982 Modecate Fluphenazine decanoate Oily Gluteal, every 2-5 weeks 1968 Piportil Pipothiazine palmitate Oily Gluteal, every 4 weeks 1983 Risperdal Consta Risperidone ZypAdhera Olanzapine pamoate Powder for reconstitution with aqueous fluid Powder for reconstitution with aqueous fluid Gluteal or Deltoid every 2 weeks Gluteal, every 2 or 4 weeks Invega Paliperidone palmitate Gluteal or Deltoid every 4- weeks. No refrigeration Late 2011

6 Background: UK depot use Use has declined in recent years (atypicals) Rates in patients in LSUs etc/prisons compared to elsewhere Compared to elsewhere: +++ Denmark, Sweden & UK France & USA

7 Survey of Psychiatrists & CPNs Old fashioned 40% 34% Stigmatising 48% 44% Less acceptable to patients 69% 61% Less acceptable to relatives 66% 49% Better for monitoring adherence 81% 99% Better for relapse prevention 94% 89% Associated with bad patients 1. Patel et al. Psychological Medicine. 2003; 33: Patel et al. J of Psychiatric and MH Nursing. 2003; 7: Patel et al. J of Psychiatric and MH Nursing. 2005; 12:

8 Why use depot? Why NOT? Promote compliance (deliberate / unintentional) Relapse prevention Some patients prefer them Our preferences?our convenience Our perceptions Needle phobic!

9 Why use depot? Why NOT? NICE?.

10 Why use depot? Why NOT? Compliance How many people are non-compliant? General population MH population? Compliance is improved by depots evidence Vrijens B et al. BMJ 2008

11 Why use depot? Why NOT? Effects of non-compliance Partial or non-compliance is associated with increased risk of: Relapse Hospitalisation Progressive brain tissue loss Further function deterioration Relapse prevention, to improve prognosis

12 Why use depot? Why NOT? Prescribing influences Individual prescribers preferences Beliefs about side effects Patients acceptance Stigma Nursing staff involvement opinions and administration External forces healthcare setting Prescribing knowledge & experience (SHOs) Correlation between knowledge and +ve attitude

13 Improving patient care? Advantages of depots Risk benefit studies show advantage of depots (outcomes, compliance & prognosis) Independent of clinic effect Cost benefit studies show benefit (lower relapse rate) Easier predication / detection of relapse No risk of intentional overdose Barnes T & Curson D. Drug Safety 1994

14 Improving patient care? Acceptability to patients How and when? and staff approach? Skill of the nurse Side effects of administration (hurts, nodules)

15 What do patients think? Majority of satisfaction studies = +ve Majority of those on depot like it Safety net protecting from relapse Easier to remember than tablets Pain of injection Intrusive or degrading nature of having an injection

16 Improving patient care? Prescribing depots well Depots are not all the same No single depot appears superior Select according to patient characteristics BNF maximum isn t necessarily the dose for optimal effect Treatment should be reviewed Not for life?non-medical prescribing role Adams C et al. Br J Psychiatry 2001; 179: Barnes T, Curson D. Drug Safety 1994; 10(6): Shajahan P et al. The Psychiatrist 2010; 43: 273-9

17 Improving patient care? Administering depots well Informed choice, site of administration Gluteal Deltoid Excellent nursing techniques! Accurate administration in obese patients

18 Improving patient care? Using depots well Advocacy & Education Informed choice Frequency of administration Who / where administration occurs Information giving / education, as per oral Side effects monitored

19 Nature of documented evidence in the case notes of clinical assessment of side effects in the last year Side effect assessment documented in the clinical records Baseline (n=5,804) Re-audit (n=5,037) No evidence of side effect monitoring 2047 (35%) 1188 (24%) General statement regarding side effects 3123 (54%) 2836 (56%) Side effect checklist/rating scale used 681 (12%) 875 (17%) Physical examination to assess side effects 629 (11%) 965 (19%) Blood tests related to side effects 710 (12%) 1081 (21%)

20 Relationship between screening for movement disorders by depot preparation prescribed in the TNS (n=5,037) at re-audit Depot prescribed Re-audit n Documented evidence of screening at re-audit (n=5045*) No evidence General statement EPS present General statement EPS not present Formal evaluation Flupentixol (66%) 259 (16%) 160 (10%) 127 (8%) Risperidone (73%) 116 (9%) 148 (12%) 64 (5%) Zuclopenthixol (62%) 158 (17%) 117 (12%) 92 (10%) Fluphenazine (68%) 93 (16%) 54 (9%) 39 (7%) Haloperidol (66%) 40 (14%) 36 (12%) 26 (9%) Pipotiazine (57%) 79 (21%) 37 (10%) 49 (13%)

21 Proportion of patients with documented evidence in their case notes of clinical assessment of EPS, weight gain & sexual side effects in the last year Baseline (n=5,804) Re-audit (n=5,037) Evidence of assessment of EPS 1801 (31%) 1693 (34%) Evidence of assessment of weight/ BMI/waist circumference 1573 (27%) 1563 (31%) Evidence of assessment of sexual side effects 544 (9%) 746 (15%)

22 Disadvantages of depots Naïve patients Unknown tolerance ( test dose is for allergy to oil and acute dystonic reactions) Risk of NMS is not with depot per se Long term movement disorders - harder to manage once induced EPS with depots as per typicals Risk of TD is not with depot per se Forced: -ve effect on therapeutic relationship Ignominious, awkward & embarrassing? GP practice nurses often refuse to give Not always reviewed Longer to manipulate doses Not always useful in acute illness too long to act

23 Improving patient care? Depot + Oral = Conundrum Depots to address non-compliance Dose limited by typical side effects (EPS) Topped up with oral atypical antipsychotics Practice helped by newer atypical depots..

24 Improving patient care? Depot + Oral Conundrum

25 Improving patient care? Incentivising? Financial incentive (NB. NTA & NICE in SMS) Proven to improve compliance Ethics. Impact of CTOs? Classen D et al. Psychiatric Bulletin 2007; 31: 4-7 Giuffrida A & Torgerson D.J. BMJ 1997; 315: 703-7

26 Depots - Improving patient care? Conclusion Depot is just a route of administration Depot is not synonymous with typical Overall goal: optimise compliance, reduce relapse, and so improve outcomes & prognosis Use depots well Maintain choice, monitor health? Are we reflecting our own biases in our patients care plans?

27 References & Further Reading Adams C et al. Systematic meta-review of depot antipsychotic drugs for people with schizophrenia. Br J Psychiatry 2001; 179: Barnes T & Curson D. Long term depot antipsychotics. Drug Safety 1994; 10(6): Classen D et al. Money for medication: financial incentives to improve medication adherence in assertive outreach. Psychiatric Bulletin 2007; 31: 4-7 Cocoman A., Murray J. Intramuscular injections: a review of best practice. J Psych Mental Health Nursing 2008; 15: Giuffrida A & Torgerson D.J. Should we pay the patient? Review of financial incentives to enhance patient complaince. BMJ 1997; 315: Nasrallah H.A. The case for long-acting antipsychotic agents in a post-catie era. Acta Psychiatrica. 2007; 115: Patel M.X., David A.S. Why aren t depot antipsychotics prescribed more often and what can be done about it? Advances in Psychiatric Treatment 2005; 11: Patel et al. Psychiatrists attitudes to maintenance medication for patients with schizophrenia. Psychological Medicine. 2003; 33: Patel et al. Eliciting Psychiatrists beliefs about side effects of typical and atypical antipsychotic drugs. J of Psychiatric and MH Nursing. 2003; 7: Patel et al. Depot antipsychotic medication and attitudes of CPNs. J of Psychiatric and MH Nursing. 2005; 12: Shajahan P et al. Comparison of the effectiveness of depot antipsychotics in routine clinical practice. The Psychiatrist 2010; 43: Vrijens B et al. BMJ Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronic complied dosing histories. Practice Guidance: Guidance on the Administration to Adults of Oil based Depot and other Long Acting Intramuscular Antipsychotic Injections. June

28 New Olanzapine depot Zypadhera It s olanzapine - originally came out in 1996 Just need to established pharmacokinetics Post-injection syndrome = overdose! Unpredictable 1.4% of patients = common Observe for 3 hours post injection Marketed to LSU ( forensic settings) Patient (informed) consent? What s your view? What do you think a patient would make of this?