The Trends of Medicine Use for Mental Disorders. Psüühikahäirete ravimite kasutamise suundumused Eestis. Dr Peeter Jaanson.

Transcription

1 Psüühikahäirete ravimite kasutamise suundumused Eestis Dr Peeter Jaanson Psühhiaater Jaansoni Psühhiaatriakeskus OÜ Ravimiameti registreerimiosakonna juhataja aastatel 1997 Taasiseseisvunud Eesti on ühe inimpõlve kestel teinud läbi olulise arengu psüühikahäirete ravimiseks mõeldud ravimite kättesaadavuse ja ravimivalikute arendamisel. Algaastatel alustati Maailma Terviseorganisatsiooni nn esmavajalike ravimite loendi ulatuses ravimite kättesaadavuse tagamisega. Praeguseks ajaks on oluliste psüühikahäirete, nagu skisofreenia ja depressiooni raviks kättesaadavad tänapäevased antipsühhootikumid ja antidepressandid. Antidepressantidest on juhtival kohal serotoniini tagasihaarde inhibiitorite kasutamine. Selles klassis on rohkelt geneerilisi ravimeid, mis teeb ka majanduslikult vähem kindlustatud haigetele ravi paremini kättesaadavaks. Geneeriliste ravimite suur osakaal näitab riigi nutikat ravimipoliitikat ravi kättesaadavuse parandamisel. Ravimite kättesaadavusele tekitab probleeme turu väiksus. Selle tõttu on turult kadunud ainus MAO inhibiitor moklobemiid ning juhtivalt noradrenaliini süsteemi toimiv reboksetiin. Antidepressantide kasutamise kasv näitab seda, et depressiooni ravitakse tõhusamalt ning perearstid tunnevad häiret paremini ära ning ka ravivad seda paremini. Antipsühhootikumidest on praegu kasutusel kõik olulisemad uuema põlvkonna ravimid, peamiselt multiretseptorantagonistide esindajad. Ravimite soodusnimekirja kandmisel on järjekindlalt püütud järgida individualiseeritud ravi põhimõtte raken- The Trends of Medicine Use for Mental Disorders Dr Peeter Jaanson Psychiatrist Jaansoni Psühhiaatriakeskus OÜ Head of the Registration Department of the State Agency of Medicines in 1997 The newly independent Estonia has, during one generation, gone through important developments in the availability of medicines intended for the treatment of mental disorders and seen considerable progress in the relevant selection of medicines. During the first years, we began with ensuring the availability of medicines in WHO s list of essential medicines. By now, a modern selection of antipsychotic medicines and antidepressants is available for the treatment of important mental disorders such as schizophrenia and depression. The leading antidepressants used are serotonin reuptake inhibitors. There are many generic medicines in this group, which makes treatment more accessible for the least privileged patients as well. The large share of generic medicines shows that the state has been smart in its medicine policy and in improving the accessibility of therapy. One problem associated with the availability of medicines is the size of the market. It has meant the disappearance of the only MAO inhibitor moclobemide, and reboxetine, which has a targeted impact on the noradrenaline system. The rising trend in the consumption of antidepressants shows that depression is treated more efficiently, and general practitioners are able to recognize the disease better and treat it more efficiently. Among antipsychotic medicines all the important new-generation medicines are used today, mainly from the group of multi-receptor 81

2 datavuse parandamist. Vanemaid antipsühhootikume, nn puhtaid dopamiiniantagoniste tarvitatakse endiselt. Oluline on see, et nende ravimite päevadoosid on vähenenud: nii välditakse kõrvaltoimete tekke riski. Sarnaselt antidepressantidega on turu väiksuse tõttu kadunud psühhoosihaigete ravis olulised depoo-antipsühhootikumid, mis on teatud hulgale skisofreeniahaigetele ainsaks toetusravi võimaluseks, kuna u 3% neist haigetest ei ole võimelised puuduliku haiguskriitika ja seega ka puuduliku ravisoostumuse tõttu suukaudset ravi tarvitama. Järgnevate aastate eesmärk on parandada erialaseltsi ja riigi koostöös just selle ravimirühma ravimite kättesaadavust. antagonists. There has been a consistent effort to improve the applicability of the principle of individualized treatment when adding medicines to the list of medicines reimbursed. The trend in the consumption of older-generation antipsychotic medicines, the so-called pure dopamine antagonists, has been stable. It is important to note that the daily doses of these medicines have been lowered to avoid the risk of side effects. Similarly to antidepressants, due to the size of the market, depot antipsychotics, which are important in the treatment of psychosis patients, have disappeared. For a certain number of schizophrenia patients, these are the only option of supportive therapy thanks to the fact that approximately 3% of these patients are unable to use oral medicines because of poor insight and thus, also poor compliance. The aim of the work to be done over the coming years is to improve the availability of the medicines in this medicine group in cooperation between specialty associations and the state. 82

3 ATC rühm/toimeaine(d) ATC group/active substance(s) N5 PSÜHHOLEPTIKUMID PSYCHOLEPTICS 21,13 19,13 18,89 18,76 17,38 18,82 2,55 21,56 23,16 24,31 27,8 29,1 31,96 34,5 34,57 33,32 34,3 35,72 39,46 41,41 N5A ANTIPSÜHHOOTILISED AINED ANTIPSYCHOTICS 3,63 3,92 3,59 3,65 3,87 3,92 4,34 4,26 4,41 4,66 4,51 4,77 4,57 4,91 5,48 5,65 6,14 6,4 7,2 7,57 N5AA Alifaatse külgahelaga fenotiasiinid Phenothiazines with aliphatic side-chain,75,61,59,37,3,32,38,39,35,34,32,27,28,28,3,25,23,18,21,18 N5AA1 kloorpromasiin Chlorpromazine,7,54,49,28,22,22,27,3,25,24,21,18,18,19,2,16,15,11,13,11 N5AA2 levomepromasiin Levomepromazine,5,7,9,9,8,1,11,9,1,1,11,9,9,9,9,9,8,7,8,7 N5AB Piperasiini struktuuriga fenotiasiinid Phenothiazines with piperazine structure,48,83,47,42,39,36,2,21,13,9,8,9,9,7,7,7,7,7,7,12 N5AB2 flufenasiin Fluphenazine,2,26,21,23,23,21,1,1,5,4,3,3,3,1,1,1,1,1,1,6 N5AB3 perfenasiin Perphenazine,3,5,9,6,6,8,1,9,7,3,3,4,5,6,6,6,6,7,6,6 N5AB6 trifluoperasiin Trifluoperazine,24,38,12,1,8,7,2,1,2,2,2 N5AC Piperidiini struktuuriga fenotiasiinid Phenothiazines with piperidine structure,11,24,2,25,17,2,22,16,15,16,16,6,1,1,1 <,1 <,1 <,1 <,1 <,1 N5AC1 peritsiasiin Periciazine <,1,3,5,9,4,8,8,2 <,1 <,1 <,1 <,1 <,1 <,1 <,1 N5AC2 tioridasiin Thioridazine,1,2,15,16,13,12,14,14,15,16,16,6,1,1,1 <,1 <,1 <,1 <,1 N5AD Butürofenooni derivaadid Butyrophenone derivatives 1,61 1,52 1,52 1,46 1,64 1,69 1,83 1,82 1,88 2,2 1,87 1,89 1,49 1,46 1,41 1,29 1,23 1,18 1,22 1,16 N5AD1 haloperidool Haloperidol 1,48 1,7 1,25 1,4 1,2 1,25 1,31 1,37 1,41 1,51 1,46 1,33 1,,99,95,87,82,79,82,79 N5AD3 melperoon Melperone,2,5,7,21,31,25,31,31,33,37,38,41,38,4,4,37,37,36,37,35 N5AD8 droperidool Droperidol,6,36,19,21,13,18,21,14,14,14,3,15,1,8,6,5,4,3,3,2 N5AE Indooli derivaadid Indole derivatives <,1,2 <,1,4,9,11,12,14,17,17,17 N5AE3 sertindool Sertindole <,1,2 <,1 <,1 <,1 <,1,4,9,11,12,13,13,13,13 N5AF Tioksanteeni derivaadid Thioxanthene derivatives,6,53,65,93 1,8 1, 1,23 1,21 1,25 1,31 1,9 1,13,95,86,85,79,79,75,77,78 N5AF1 flupentiksool Flupentixol,25,9,16,32,36,34,43,39,41,37,22,21,21,2,19,18,18,17,18,19 N5AF3 kloorprotikseen Chlorprothixene,6,14,16,21,26,24,27,29,29,33,31,36,38,32,33,3,29,27,28,28 N5AF5 zuklopentiksool Zuclopenthixol,29,31,33,39,45,42,53,53,55,61,56,56,35,35,33,31,32,32,31,31 N5AH Diasepiinid, oksasepiinid ja tiasepiinid Diazepines, oxazepines and thiazepines,4,12,5,11,15,18,21,22,27,34,53,76 1,5 1,37 1,83 2,17 2,63 2,95 3,54 3,87 N5AH2 klosapiin Clozapine,4,12,5,1,14,16,19,21,25,3,32,3,32,33,39,43,48,51,56,57 N5AH3 olansapiin Olanzapine <,1 <,1,2,2,1,2,1,8,26,41,61,79,87,98 1,8 1,3 1,48 N5AH4 kvetiapiin Quetiapine <,1 <,1 <,1,3,13,2,31,43,65,86 1,16 1,37 1,68 1,82 N5AL Bensamiidid Benzamides <,1,1,1,2,2,4,4,4,5,9,11,11,12,12,12,11,1,1,1,12 N5AL1 sulpiriid Sulpiride <,1,1,1,2,2,4,4,4,5,5,5,4,5,5,5,5,5,5,5,6 N5AL5 amisulpriid Amisulpride <,1 <,1,4,6,7,7,7,6,6,5,6,5,6 83

4 Antipsühhootikumide kasutamine Eestis 213 Consumption of antipsychotics in Estonia 213 DPD/1/ööpäevas DDD/1 inhabitants/day Liitium Lithium Bensamiidid Benzamides Indooli derivaadid Indole derivatives Piperidiini struktuuriga fenotiasiinid Phenothiazines with piperidine structure Piperasiini struktuuriga fenotiasiinid Phenothiazines with piperazine structure Alifaatse külgahelaga fenotiasiinid Phenothiazines with aliphatic side-chain Tioksanteeni derivaadid Thioxanthene derivatives Teised antipsühhootilised ained Other antipsychotics Butürofenooni derivaadid Butyrophenone derivatives Diasepiinid, oksasepiinid ja tiasepiinid Diazepines, oxazepines and thiazepines 84

5 ATC rühm/toimeaine(d) ATC group/active substance(s) N5AN Liitium Lithium,3,5,9,8,9,11,15,13,15,14,14,14,14,13,13,13,16,16,17,18 N5AN1 liitium Lithium,3,5,9,8,9,11,15,13,15,14,14,14,14,13,13,13,16,16,17,18 N5AX Teised antipsühhootil ised ained Other antipsychotics <,1,1,3,8,8,18,17,21,32,41,52,64,73,79,83,94 1, N5AX8 risperidoon Risperidone,1,3,8,8,18,17,21,32,41,44,48,48,49,5,57,58 N5AX12 aripiprasool Aripiprazole <,1 <,1,7,16,25,3,33,37,41 N5B ANKSIOLÜÜTIKUMID ANXIOLYTICS 1,87 1,56 9,49 8,98 8,37 8,76 8,25 8,19 9,37 1,38 12,22 12,86 14,47 14,83 14,19 13,25 13,12 13,36 14,35 14,82 N5BA Bensodiasepiini derivaadid Benzodiazepine derivatives 1,81 1,52 9,48 8,97 8,37 8,76 8,25 8,19 9,37 1,38 12,22 12,86 14,47 14,83 14,19 13,25 13,12 13,36 14,35 14,81 N5BA1 diasepaam Diazepam 3,6 3,42 3,71 3,76 3,18 3,37 4,34 4,34 4,96 5,46 6,13 6,1 6,88 6,58 6,52 6,13 6,8 6,13 6,67 6,97 N5BA4 oksasepaam Oxazepam 1,7 2,5 2,5 1,73 1,47 1,35 1,56 1,9,73,49,52,25,3,3,4,5,5,4,5,6 N5BA5 dikaaliumkloorasepaat Potassium clorazepate,3,8,14,14,14,7 <,1 <,1 <,1 N5BA6 lorasepaam Lorazepam,18,16,65,78,81,33,55,11,3,2,2,1,2,1 <,1 <,1 <,1 <,1 <,1,2 N5BA8 bromasepaam Bromazepam,2,4,24,42,69,83,88 1,1 1,8 1,22 1,34 1,43 1,37 1,41 1,4 1,48 1,47 N5BA12 alprasolaam Alprazolam <,1,5,13,2,32,66 1,3 1,95 2,8 3,51 4,48 5,48 6,29 6,82 6,15 5,64 5,55 5,74 6,1 6,25 N5BA8 fenasepaam Phenazepam 4,29 3,76 1,84 1,71 2,3 2,32,1,1,2,2,6,3,4,4,4,4,4,4,4,4 N5C UINUTID JA RAHUSTID HYPNOTICS AND SEDATIVES 6,62 4,64 5,81 6,13 5,14 6,14 7,96 9,11 9,38 9,27 1,35 11,38 12,92 14,31 14,89 14,42 14,76 15,96 17,91 19,3 N5CA Barbituraadid Barbiturates, plain 3,48 2,22 1,58 1,28,27 N5CA2 amobarbitaal Amobarbital 3,48 2,22 1,58 1,28,27 N5CB Barbituraatide kombinatsioonid Barbiturates, combinations,3,31,35,19,11 <,1 N5CD Bensodiasepiini derivaadid Benzodiazepine derivatives 2,82 2,4 3,57 3,44 3,66 3,78 4,65 4,9 4,32 3,83 3,53 3,53 3,72 3,57 3,1 2,47 2,8 1,94 1,5 1,28 N5CD2 nitrasepaam Nitrazepam 1,47 1,65 2,56 2,43 2,67 2,92 3,18 3,13 2,69 2,82 2,92 2,86 2,95 2,63 2,51 2,7 1,77 1,6 1,7,92 N5CD3 flunitrasepaam Flunitrazepam 1,32,3,92,86,87,71 1,23 1,51 1,42,79,23,14 N5CD5 triasolaam Triazolam <,1,5,1,2,1 <,1,2,3,4,4,5,6,6,7,5,5,4,4,5,5 N5CD7 temasepaam Temazepam,3,3,6,4,3 <,1,5,7,1 <,1 N5CD8 midasolaam Midazolam <,1,1,2,6,8,13,17,16,16,18,33,47,71,86,46,35,27,3,38,31 N5CF Bensodiasepiinisarnased ained Benzodiazepine related drugs <,1,5,31 1,21 1,1 2,36 3,31 4,21 5,6 5,44 6,82 7,85 9,18 1,68 11,73 11,86 12,61 13,94 16,32 17,68 N5CF1 zopikloon Zopiclone <,1,5,31 1,21 1,1 2,36 3,3 3,81 4,5 4,91 6,8 6,96 8,9 9,33 1,6 1,4 1,63 11,67 13,56 14,61 N5CF2 zolpideem Zolpidem <,1,1,4,56,53,74,89 1,8 1,35 1,67 1,82 1,98 2,27 2,76 3,7 N5CH Melatoniiniretseptori agonistid Melatonin receptor agonists,1,12,8,7,8,9,6 N5CH1 melatoniin Melatonin,1,12,8,7,8,9,6 85

6 Anksiolüütikumide kasutamine Eestis 213 Consumption of anxiolytics in Estonia 213 DPD/1/ööpäevas DDD/1 inhabitants/day Lorasepaam Lorazepam Dikaaliumkloorasepaat Potassium clorazepate Fenasepaam Phenazepam Oksasepaam Oxazepam Bromasepaam Bromazepam Alprasolaam Alprazolam Diasepaam Diazepam DPD/1/ööpäevas DDD/1 inhabitants/day Uinutite ja rahustite kasutamine Eestis 213 Consumption of hypnotics and sedatives in Estonia Melatoniin Melatonin Temasepaam Temazepam Triasolaam Triazolam Flunitrasepaam Flunitrazepam Midasolaam Midazolam Nitrasepaam Nitrazepam Zolpideem Zolpidem Amobarbitaal Amobarbital Zopikloon Zopiclone 86

7 ATC rühm/toimeaine(d) ATC group/active substance(s) N6A ANTIDEPRESSANDID ANTIDEPRESSANTS 1,75 2,19 2,7 3,96 5,66 4,97 6,34 7,88 9,6 1,52 12,18 12,75 13,8 14,23 14,72 14,43 15,83 17,81 2,62 21,93 N6AA Mitteselektiivsed monoamiini tagasihaarde inhibiitorid Non-selective monoamine reuptake inhibitors 1,63 1,94 2,13 2,87 3,78 2,92 3,26 3,46 3,27 3,15 3,15 2,89 2,68 2,36 2,21 2,5 2,5 1,99 2,14 2,14 N6AA2 imipramiin Imipramine,2,14,13,12,9,5,7,6,5,5,7,3,1,1,1,1 <,1 <,1 <,1 <,1 N6AA4 klomipramiin Clomipramine <,1,2,4,4,5,8,9,1,1,11,1,9,9,7,8,7,7,6,7,7 N6AA9 amitriptüliin Amitriptyline 1,4 1,68 1,75 1,62 1,69 1,46 1,59 1,7 1,67 1,87 1,92 1,83 1,81 1,6 1,51 1,44 1,47 1,44 1,56 1,58 N6AA1 nortriptüliin Nortriptyline,2,6,16,97 1,89 1,26 1,48 1,6 1,45 1,12 1,6,94,77,68,61,54,51,48,5,48 N6AA21 maprotiliin Maprotiline,1,4,5,12,6,7,3 <,1 <,1 <,1 <,1 <,1 N6AB Selektiivsed serotoniini tagasihaarde inhibiitorid Selective serotonin reuptake inhibitors,1,2,54 1,4 1,84 1,98 2,89 4,1 5,39 6,82 8,29 8,79 9,13 9,14 9,32 8,92 1,18 11,46 13,24 14,17 N6AB3 fluoksetiin Fluoxetine,2,6,1,19,47,65,68 1,31 2,2 2,6 2,76 2,62 2,52 2,36 2,35 2,25 2,31 2,42 2,64 2,81 N6AB4 tsitalopraam Citalopram,8,14,44,82 1,32 1,21 1,66 1,97 1,95 1,2 1,63 1,91 2,4 2,7 2,8 2,4 1,86 1,65 1,72 1,59 N6AB5 paroksetiin Paroxetine,35,64,69,89 1,29 1,53 1,64 1,57 1,68 1,63 1,59 1,7 1,93 2,6 N6AB6 sertraliin Sertraline <,1 <,1 <,1,3,9,17,15,14,25,8 1,4 1,21 1,31 1,3 1,39 1,45 1,64 2,1 2,37 N6AB8 fluvoksamiin Fluvoxamine <,1 <,1 <,1,3,2,3,3,3,3,5,3,3,2,1,1,1,1,1 <,1,1 N6AB1 estsitalopraam Escitalopram,38 2,1 1,78 1,66 1,69 1,82 1,9 1,59 2,96 4,3 4,84 5,33 N6AG Monoamiini oksüdaasi A (MAO-A) inhibiitorid Monoamine oxidase A inhibitors,4,1,4,3,3,2,2,2,2,2,1 N6AG2 moklobemiid Moclobemide,4,1,4,3,3,2,2,2,2,2,1 N6AX Teised antidepressandid Other antidepressants <,1,1,1,1,4,17,3,38,53,72 1,6 1,99 2,72 3,19 3,46 3,6 4,36 5,24 5,62 N6AX3 mianseriin Mianserin <,1,1,1 <,1,1,1 <,1 <,1 <,1 <,1 N6AX11 mirtasapiin Mirtazapine <,1,7,12,11,14,23,42,85 1,13 1,28 1,26 1,21 1,41 1,57 1,63 N6AX12 bupropioon Bupropione,1,3,2,2,6,18,23,23,2,17,17,18,22,26 N6AX14 tianeptiin Tianeptin <,1 <,1 <,1,1,5,1,15,22,23,32,46,6,61,65,79,94,97 N6AX16 venlafaksiin Venlafaxine <,1,2,8,8,13,19,17,21,31,39,54,9 1,2 1,26 1,68 1,73 N6AX17 milnatsipraan Milnacipran <,1,2,3,1,13,13,8,6,3,4,4,3 N6AX18 reboksetiin Reboxetine <,1,1,2,1,1,1,1,1,1,1 <,1 <,1 <,1 N6AX21 duloksetiin Duloxetine <,1,14,38,48,45,48,61,73,93 N6AX22 agomelatiin Agomelatine,3,6,7,7 87

8 Antidepressantide kasutamine Eestis 213 Consumption of antidepressants in Estonia 213 DPD/1/ööpäevas DDD/1 inhabitants/day Monoamiini oksüdaasi A (MAO-A) inhibiitorid Monoamine oxidase A inhibitors Mitteselektiivsed monoamiini tagasihaarde inhibiitorid Non-selective monoamine reuptake inhibitors Teised antidepressandid Other antidepressants Selektiivsed serotoniini tagasihaarde inhibiitorid Selective serotonin reuptake inhibitors Selektiivsete serotoniini tagasihaarde inhibiitorite kasutamine Eestis 213 Consumption of selective serotonin reuptake inhibitors in Estonia 213 DPD/1/ööpäevas DDD/1 inhabitants/day Estsitalopraam Escitalopram Fluoksetiin Fluoxetine Sertraliin Sertraline Paroksetiin Paroxetine Tsitalopraam Citalopram Fluvoksamiin Fluvoxamine 88