Assessing & Management of side effects: Part 1. medicationmanagement

Transcription

1 Assessing & Management of side effects: Part 1 medicationmanagement

2 What side effects of antipsychotic medication do you see in you clinical practice?

3 How do you routinely assess for side effects of medication?

4 Potential side effects Central nervous system Movement disorders [EPSEs] Thermoregulatory effects [NMS] Central anticholinergic toxicity Sedation Cardiovascular Hypotension Tachycardia EGC changes Haematological Neutropenia Leukopenia Agranularcytosis Gastrointestinal effects Sialorrhoea Constipation Opthalmological Neuroendocrine Hyperprolactineamia Sexual dysfunction Weight gain Glucose and lipid metabolism Genitourinary [incontinence] Dermatological [rashes]

5 Mechanism of Action Dopamine hypothesis of schizophrenia Schizophrenia is associated with impaired dopaminergic neurotransmission in the brain Mesocortical pathway - Learning and memory Hypoactivity: Negative symptoms Mesolimbic pathway - Emotions Hyperactivity: Positive symptoms Tuberoinfundibular pathway - Prolactin regulation Nigrostriatal pathway - Movement regulation Stahl SM. Essential Psychopharmacology of antipsychotics and mood stabilizers. 1st ed. Cambridge: Cambridge University Press; 2002

6 Broad receptor binding profile Olanzapine Clozapine Haloperidol Risperidone D1 D2 D4 5-HT2A 5-HT2C Musc α1-adren. α2-adren. Hist. H1 Sertindole Quetiapine Ziprasidone Zotepine Chlorpromazine Data from Bymaster et al., 1996, unpublished observations; Schotte et al., 1996,

7 Mesocortical pathway Increase in negative symptoms Stahl, Essential Psychopharmacology;Cambridge University Press 2000

8 Nigrostriatal pathway EPSs Stahl, Essential Psychopharmacology;Cambridge University Press 2000

9 Tuberoinfundibular pathway Prolactin levels rise Stahl, Essential Psychopharmacology;Cambridge University Press 2000

10 1 INSERTED decreased blood pressure dizziness drowsiness Stahl, Essential Psychopharmacology;Cambridge University Press 2000

11 M1 INSERTED constipation blurred vision LAXATIVE dry mouth drowsiness Stahl, Essential Psychopharmacology;Cambridge University Press 2000

12 H1 INSERTED drowsiness weight gain Stahl, Essential Psychopharmacology;Cambridge University Press 2000

13 5HT2A 1 2 risperidone D2 5HT7 Stahl, Essential Psychopharmacology;Cambridge University Press 2000

14 5HT2A H HT6 quetiapine D2 5HT7 Stahl, Essential Psychopharmacology;Cambridge University Press 2000

15 5HT1A 5HT2A M1 H HT2C 5HT3 5HT6 clozapine D4 D3 D2 D1 5HT7

16 5HT2A M1 H1 1 5HT2C 5HT3 5HT6 olanzapine D4 D3 D2 D1 Stahl, Essential Psychopharmacology;Cambridge University Press 2000

17 5HT1A 5HT2A 1 5HT1D 5HT2C SRI NRI ziprasidone D3 D2 5HT7 Stahl, Essential Psychopharmacology;Cambridge University Press 2000

18 Current practice Survey of 250 CPNs/Thorn graduates CPNs report that medication management is part of their role Routinely monitor psychopathology; side effects Very high priority for training Measures infrequently used (KGV 5%; LUNSERS 25%) 25% ask about sexual dysfunction Thorn training improves reported practice Gray R. et al (2001) JP&MHN, 7, 4, 12-18

19 Use of measures Percentage CPNs Thorn graduates LUNSERS SIMPSON AIMS OWN

20 General side effect assessment tools

21 LUNSERS Based on the UKU Self-report Symptom experienced in the last month 51-items rated on a five point scale Red herrings Sub-scales Some validity/reliability data available Advantages Easy to use Comprehensive Allows side effects to be prioritised Disadvantages Side effects will be missed Time consuming to score Dubious red herrings Some patients are unable to complete

22 LUNSERS sub-scales Extrapyramidal symptoms Anticholinergic effects Other autonomic Dizziness; feeling sick; palpitations; etc Allergic reactions Psychic side effects Sedation; tension; depression; etc Hormonal side effects Miscellaneous Red herrings

23 Example items from the LUNSERS Each item is rated on a five point scale Not at all; very little; a little; quite a lot; very much Rash Difficulty staying awake Runny nose Increased dreaming Headaches Dry mouth Swollen or tender chest

24 What are EPSEs?

25 Dystonia Signs & symptoms How common is it? How long does it take to develop? Assessment Treatment Muscle spasm in any part of the body. Trismus (contraction of the masculatory muscles);blepharospasm (sustained forceful eye closure); Facial grimacing; Oculogyric spasm (eyes rolling back) Tortocolis (head and neck twisted to the side); Retrocolis (head and neck forced back): laryngeal spasm Patient may be unable to speak or swallow Approx 10%. Associated with typicals. More common in young men, drug naïve, high potency meds Minutes after administering IM, hours after oral (acute) monthsyears (tardive) observation Administration of anticholinergic meds Oral (patient may not be able to swallow) IM (response 20 minutes) IV ( response 5 minutes)

26 Pseudo-parkinsonism Signs & symptoms How common is it? How long does it take to develop? Assessment Treatment Motor symptoms: Rigidity (limbs resistive to passive movements); tremor; postural abnormalities; Bradykinesia or akinesia (characterised by a reduction in spontaneous facial movements); decreased facial expression, flat monotone voice, decreased arm swing, inability to initiate movement Mental effects: Bradyphrenia (slow thinking), mental clouding salivation Approx 20% more common in elderly females, pre existing head injury, stroke Days to weeks Simpson & Angus EPSE rating scale. Observation. Patient report Reduce dose Change to atypical Prescribe anticholinergic

27 Simpson-Angus Scale (SAS) Reference: Simpson GN and Angus JWS (1970) Acta Psych Scand, 212 (sup 44), item measure for drug induced parkinsonism Facilitates standardised clinical assessment of Rigidity, tremor and salivation Has validity Ten items rated on a five point scale (0=complete absence of the condition, 4=presence of the condition in extreme form) 7/10 items measure rigidity Shoulder shaking, arm dropping, and elbow and wrist rigidity Items from tremor and pooling of saliva in the mouth The global score in the summation of all the items divided by the number of items Scores of up to 0.3 are considered within the normal range

28 Model for assessing side effects

29 Model for assessing side effects LUNSERS+observation every six months Observe or pt reports stiffness: Simpson/Angus scale Feedback to the patient Discussion with multi-disciplinary team Feedback to the patient Management: consult Maudsley prescribing guidelines Review and re assess

30 akathesia Signs & symptoms Can t sit still ; Subjective inner restless; foot stamping when sitting down; rocking from foot to foot; pacing; mental unease, unrest or dysphoria How common is it? Approx 25% How long does it take to develop? Assessment Treatment Hours to weeks Barnes Akathisia Scale. Observation, patient report Reduce dose Switch to atypical (clozapine, quetiapine) Antimuscarinic (benzatropine) Propranalol/diazepam/clonazepam * Anticholinergics not useful for akathesia

31 Barnes akathesia rating scale (BAS or BARS) Reference Barnes TRE (1989) Br J Psych 154, Measures Objective features of motor restlessness Subjective complaints of restlessness And associated distress Rated on a scale of 0-3 Operational definitions for each scale point Also a global severity rating on a six-point scale (0=absent, 5=severe) Diagnostic for mild moderate and severe akathisia Scale should be completed after observation of the patient for five minutes

32 Model for assessing side effects LUNSERS+observation every six months Observe or pt reports restlessness: Barnes akathisia scale Feedback to the patient Discussion with multi-disciplinary team Feedback to the patient Management: consult Maudsley prescribing guidelines Review and re assess

33 Tardive Dyskinesia Signs & symptoms How common is it? How long does it take to develop? Assessment Treatment Involuntary repetitive movements. Perioral movements (lip smacking, sucking, darting, twisting tongue, chewing, lip puckering, puffing cheeks) facial and eye (grimacing, tics, blinking, brow arching) extremities and trunk (choriform movements) noisy breathing 5% after first year of exposure. More common in females, people with negative symptoms, co morbidity dementia, mood disorder, diabetes). The longer the exposure the greater the risk Months to years Abnormal Involuntary movement Scale (AIMS) Observation, patient report Stop anticholinergic medication. Switch to an atypical (clozapine, olanzapine, quetiapine). Tetrabenazine, clonazepam, vitamin E

34 Treatment outcome Parkinsonism and dystonia not associated with a worse outcome Akathisia associated with a worse outcome Suicide/violence

35 The course of EPS 30 Fig 1. The time course of acute extrapyramidal symptoms (Casey 1996) EPS (% of patients) Akathisia Dystonia Parkinsonism Time (days)

36 Overview of the AIMS Introduced by US National Institute of Mental Health (NIMH) - Guy (1976) Global instrument Divided into seven body regions Each item rated on a five point scale Additionally global ratings of Overall severity Incapacitation Patient awareness Dental status can be recorded Tremor is excluded Total score of 0-40 Detailed examination protocol AIMS rating scale 0= None/normal 1= Minimal 2= Mild 3= Moderate 4= Severe

37 Model for assessing side effects LUNSERS+observation every six months Observe unusual movements (not rhythmic): AIMS Feedback to the patient Discussion with multi-disciplinary team Feedback to the patient Management: consult Maudsley prescribing guidelines Review and re assess

38 Problem solving Formulation Brief summary of assessments agreed by interviewer and patient Problem identification (SM) Target (SMART) Evidence based intervention Agree plan review

39 Single case study design LUNSERS Baseline assessment Formulation/problems and targets Specific problems Design intervention Implement intervention 0 Evaluation Baseline Evaluation Durability Durability

40 Rating scales General - LUNSERS Parkinsonism Simpson-Angus Akathisia Barnes Akathisia Scale Tardive Dyskinesia Abnormal Involuntary Movement Scale (AIMS)

41 Role play exercise In pairs: Practice: Introducing the LUNSERS to the patient Work through the assessment (guided completion notion..) For any side effect identified rate the associated distress if you have time consider the grouping of SE s experienced (how may their prescription be contributing to this?) FEEDBACK TO GROUP