HIV Case Conference: Use of Anti Psychotics for Non Psychotic Disorders

Transcription

1 AM1 F/C AETC Faculty Psych Thursday, June 19, :30 1:30pm (EDT) Facilitator Debbie Cestaro Seifer, MS, RN University of South Florida Didactic Presenter Patrick Marsh, MD University of South Florida HIV Case Conference: Use of Anti Psychotics for Non Psychotic Disorders Patrick Marsh, MD Faculty, Florida/Caribbean AIDS Education and Training Center Assistant Professor, College Of Medicine, Psychiatry And Behavioral Neurosciences, USF Health Morsani College of Medicine (Up to 1.0 hour of CE/CME) 1

2 Slide 1 AM1 Allison Moxam, 6/9/2014

3 Learning Objectives Participants will be able to: recognize common adverse reactions to antipsychotic medications list FDA approved indications for antipsychotics for non psychotic disorders recognize the recommendation for periodic re evaluation of antipsychotic treatment Primary Psychotic Disorders Schizophrenia Schizoaffective disorder Delusional Disorder Schizophreniform disorder Brief psychotic disorder APA

4 Bad Medicine Astra Zeneca and Seroquel/Quetiapine Paid $1.5 billion in legal costs and settlements for off label marketing of the drug $520 million to the Department of Justice $743 million in legal costs in unresolved cases $198 million in civil settlements. Duff 2011 Number need to Harm In elderly patients risk of death [NNH] = 87 stroke NNH = 53 for risperidone, extrapyramidal symptoms NNH = 10 for olanzapine; NNH = 20 for risperidone, and urinary tract symptoms NNH range = In nonelderly adults, adverse events included weight gain (particularly with olanzapine), fatigue, sedation, akathisia (for aripiprazole), and extrapyramidal symptoms. Maher

5 Akathisia Subjectively Unease, distress, dysphoria, inner sense of restlessness Objectively Repetitive movements of the legs and feet Pacing, walking in place, rocking, stand and sit Extremely distressing can lead to suicide Haddad 2008 Akathisia Treatment Beta Blocker Propranolol Pindolol Benzodiazepines Clonazepam Diazepam Haddad

6 Dystonia Contraction of a voluntary muscle to its maximal degree that is sustained and so leads to a postural distortion Most common site is the neck Any muscle can be involved Extra ocular muscles well documented but rare (oculogyric crisis) Occurs within one week of starting or increasing antipsychotic Haddad 2008 Dystonia Treatment Discontinue the antipsychotic Change to lower potency Anticholinergics Benadryl (for acute dystonia IM/IV) trihexyphenidyl benztropine Haddad

7 Tardive Dyskinesia Abnormal involuntary movements of the tongue, lips, face, trunk, and extremities which are the result of long term use of dopamine antagonists. Once TD is present it is difficult to treat. Prevention via limiting use of antipsychotics is the most effective strategy. Haddad 2008 Chlorpromazine/Thorazine Hicups 25 50mg tid Tetanus 25 50mg q6 8h Acute intermittent porphyria 25 50mg tid qid Preop sedation mg Nausea/vomiting 10 25mg q4 6h PDR

8 Major Depression Abilify/aripiprazole There is limited evidence of efficacy for atypical antipsychotics for the treatment of non psychotic depression. Aripiprazole package insert Bipolar Depression Quetiapine Olanzapine (with fluoxetine) Lurasidone PDR

9 Acute Mania Olanzapine Chlorpromazine Ziprasidone Risperdone Quetiapine Aripiprazole Asenapine PDR 2013 Anxiety There are no antipsychotics approved by the FDA for anxiety disorders. There is fair evidence for the use of atypical antipsychotics as adjunctive treatment of Obsessive Compulsive Disorder. (grade IB) There is limited evidence for the use of atypical antipsychotics as adjunctive treatment of Post Traumatic Stress Disorder and Generalized Anxiety Disorder (grade IB) Hershenberg 2014, Sullivan 2009, Dold 2013 Shekelle 1999 (evidence grading) 8

10 Sleep There are no antipsychotics approved by the FDA for insomnia or sleep promotion. Most antipsychotics will produce significant sedation when given acutely. Dementia Associated Agitation All antipsychotics are black boxed for increase risk of stroke and death in dementia patients. There is limited evidence for efficacy of antipsychotics for agitation in dementia Despite the above use of antipsychotics in the demented patient are exceedingly common. Ballard 2006 Declercq

11 Reevaluation Consideration should be made at least every 6 months on the risk benefit of the use of an antipsychotic and the possibility of stopping the medication. References Maher AR, Maglione M, Bagley S, Suttorp M, Hu JH, Ewing B, Wang Z, Timmer M, Sultzer D, Shekelle PG. Efficacy and comparative effectiveness of atypical antipsychotic medications for off label uses in adults: a systematic review and metaanalysis. JAMA Sep 28;306(12): DUFF WILSON AstraZeneca Settles Most Seroquel Suits July 28, 2011, New York Times Nelson JC, Papakostas GI Atypical antipsychotic augmentation in major depressive disorder: a meta analysis of placebocontrolled randomized trials. Am J Psychiatry. 2009;166(9):980 Rana AQ, Chaudry ZM, Blanchet PJ. New and emerging treatments for symptomatic tardive dyskinesia. Drug Des Devel Ther Nov 6;7: Haddad PM, Dursun SM. Neurological complications of psychiatric drugs: clinical features and management. Hum Psychopharmacol Jan;23 Suppl 1: Declercq T, Petrovic M, Azermai M, Vander Stichele R, De Sutter AI, van Driel ML, Christiaens T. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev Mar 28. Ballard C, Waite J. The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer's disease.cochrane Database Syst Rev Jan 25 Dold M, Aigner M, Lanzenberger R, Kasper S. Antipsychotic augmentation of serotonin reuptake inhibitors in treatmentresistant obsessive compulsive disorder: a meta analysis of double blind, randomized, placebo controlled trials. Int J Neuropsychopharmacol Apr;16(3): Sullivan GM, Neria Y. Pharmacotherapy in post traumatic stress disorder: evidence from randomized controlled trials.curr Opin Investig Drugs Jan;10(1): Hershenberg R, Gros DF, Brawman Mintzer O. Role of Atypical Antipsychotics in the Treatment of Generalized Anxiety Disorder. CNS Drugs May 5 Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Developing clinical guidelines West J Med. 170(6):348 51, 1999 June) 10

12 Question & Answer Session 11