Monday, March 14, 2005
Paper 2
Schizophrenia remains one of the most severe, chronic, and debilitating psychiatric disorders. Generally beginning in late adolescence or early adulthood, it effects approximately 1% of the population. The disease is characterized by a variety of symptoms along four dimensions: positive symptoms, negative symptoms, cognitive impairments, and disturbances in mood and affect. Life expectancy….
The first medications to treat schizophrenia were introduced in the 1950s. While these early, or “conventional” antipsychotics have been very effective at treating the positive symptoms of the disease, they also tend to cause devastating extrapyramidal motor symptom side effects (EPS) and often irreversible tardive dyskinesia (TD). The symptoms of EPS mimic that of Parkinson’s Disease and include things such as tremor, akathisia, and acute dystonia. TD causes uncontrollable facial and tongue movements like chewing and grimacing and hyperkinetic activity in the distal extremities.
Treatment with pharmaceutical agents like haloperidol, thioridazine, or chlorpromazine control the psychotic aspects of schizophrenia by blocking dopamine type 2 (D2) receptors in the mesolimbic pathway in the brain (402). Unfortunately there are also D2 receptors in other areas of the brain, specifically the substantia nigra and basal ganlia that these agents will block as well which initially cause EPS. With chronic blockade of D2 receptors in the nigrostriatal pathway, EPS will progress to TD at a rate of 4% per year of exposure to the antipsychotic agent.
The development of movement related side effects further increase the social stigma that schizophrenic patients face, making it very difficult to encourage patients to remain compliant with these agents for any length of time. Once patients discontinue treatment psychosis will typically relapse at a rate of approximately 10% per month, so that 50% or more have relapsed by 6 months after the medication is discontinued. (408)
In 1990, clozapine, the first of the new or “atypical” antipsychotics was approved by the FDA for the treatment of schizophrenia. The new agents were given the title of “atypical” because of their similar clinical properties, most noteably their low rates of EPS and efficacy for treating negative symptoms of schizophrenia. Pharmacologically speaking, the medications in this class have chemical structures that are very different from one another, howver they all act on the same receptors in the brain.
Like their conventional counterparts, the atypicals treat the positive symptoms of schizophrenia by blocking D2 receptors. In addition to D2 receptor blockade, the atypicals block serontonin 2A (5HT2A) receptors as well, which helps to explain why these agents are also effective at treating the negative, cognitive, and affective symptoms of schizophrenia. (416)
This antagonism of the 5HT2A receptors in the nigrastriatal pathways of the brain is also thought to be responsible for the relative lack of EPS seen with the atypical agents. 5HT2A antagonism in the nigrostraital pathway leads to the reversal of D2 receptor blockade in the area and blocking 5HT2A receptors also stimulates the release of dopamine in the nigrostriatial pathway. With an increase presence of dopamine in the substansia nigra, the extrapyramidal side effects are virtually eliminated. (417).
As a class, the atypical antipsychotics, have virtually taken over the treatment of schizophrenia, and account for approximately 80% of all antipsychotics prescribed in the United States. (Tandon) There are currently six atypical antipsychotics approved for use in the United States- clozapine (Clozaril), olanzapine (Zyprexa), qutiapine (Seroquel), risperidone (Risperdal), zisprazadone (Geodon), and aripiprazole (Abilify). Clozapine remains the most effect agent available for treating all four dimensions of schizophrenia symptoms. However, it has been associated with agranulocytosis, a rare but life threatening side effect, so its use is reserved for treatment resistant patients.
As experience with the atypical antipsychotics grows, other similarities amongst the different drugs in the class are becoming evident as well. Perhaps the most other most notable similarity with these agents are the metabolic disturbances that often arise in patients that take them. Increased rates of type 2 diabetes, hyperlipidemia, and obesity have all been associated with atypical antipsychotic treatment.
Diabetes:
Type 2 diabetes is a serious health problem in the United States. In 2002 the CDC estimated that approximately 6.3% of the population, or 18.2 million Americans suffer from the disease, and 90% of those have type 2 diabetes (CDC). People with diabetes have a risk of developing heart disease that is 2-4 times greater than that of the general population and diabetes is currently the sixth leading cause of death in the United States (CDC).
Schizophrenia itself appears to carry an increased risk of diabetes unrelated to treatment with antipsychotics. A study of first episode, drug-naïve schizophrenia patients found high rates impaired glucose metabolism, a precursor for the development of type 2 diabetes. Impaired fasting glucose tolerance was observed in 15.4% of the patients with schizophrenia, compared to none of the matched healthy comparison subjects (sas).
Use of antipsychotic medication also appears to increase the risks of developing type 2 diabetes. Rates of diabetes have been found to be higher in patients treated with both typical and atypical antipsychotics than in the general population. A retrospective analysis of more than 56,000 patients treated with antipsychotics (both conventional and atypical) estimated the annual incidence rate of diabetes to be 4.4%, a rate considerably higher than the expected 6.3 cases per 1000 people annually the general U.S. population. (lelise).
The risks may be even greater for younger patients treated with antipsychotic medication. The rate of diabetes for people between the ages of 20-39 in the general U.S. population is 1.1%. Rates of diabetes between 6.2-8.7% were observed in a retrospective analysis of more than 4000 people between the ages of 20-39 who received treatment with a conventional or atypical agent. (sernyak)
There is also evidence available to suggest that the use of atypical agents may be associated with a higher rate of diabetes compared to the use of conventional agents. After controlling for the effects of age, a retrospective comparison of 38,632 patients on antispcychotic therapy: 15,984 on conventional agents and 22,648 on atypical agents, found that paitents who received atypical neuroleptics were 9% more likey to have diabetes than those who receivd conventional agents. (sernyak)
Among the atypical agents, clozapine and olanzapine appear to carry the greatest risk of causing abnormalities in glucose metabolism. At the end of a 5 year study of 82 patients being treated with clozapine, 30 (36.6%) were found to have been diagnosed with type 2 diabetes (Henderson). Another study involving almost 6000 patients using either olanzepine or risperidone found that the risk of developing diabetes was 37% higher in the patients treated with olanzepine. (Medscape).
At current time it appears that the two most recently approved antipsychotics, ziprasadone and aripiprazole, carry the lowest risk for developing diabetes of all the atypical agents (something). Use of quetiapine and risperidone appear to carry a greater risk of diabetes than ziprazpdone or aripiprazole, but less than clozapine and olanzepine. Experience with clozapine and olanzepine is still greater than experience with any of the other atypical agents. Because of this fact it’s reasonable to believe that as time goes on, different conclusions may be reached on the relative propensity to cause diabetes among the atypical antipsychotics.
Weight Gain:
Obesity is a growing epidemic in the United States with almost two-thirds of the population being classified as overweight (BMI > 25 kg/M2), and obesity itself is a well established cause of type 2 diabetes (cdc). There are also well established risk factors that put an individual at an increased risk for being overweight. These risk factors include things like smoking, sedentary lifestyle, and poor diet as a result of lower socio-economic class. In general these risk factors are common among patients with psychiatric illnesses (Sachthansknsa).
Although data is limited, there is some evidence to suggest that the rate of obesity in patients with schizophrenia and affective disorders in medication naïve patients is approximately 1.5-2 times higher than that of the general population. (ADA). There is greater evidence to suggest that treatment with an antipsychotic, whether it is conventional or atypical, results in significant weight gain. Published reports show that as many as 50% of patients will show substantial increases in weight with long term antipsychotic treatment (Sathay). The relative frequency with which weight gain occurs seems to vary with each drug.
Allison, et al preformed a meta-analysis on published reports of changes in weight occurring ten weeks after the initiation of therapy with a neuroleptic. Their findings showed that almost all of the commercially available antipsychotics, regardless of whether they are classified as convetional or atypical agents, cause some degree of weight gain when compared to a placebo. Thioridazine and chlorpromazine were the conventional agents associated with the largest average degree of weight change, at 3.49 kg and 2.10 kg respectively. Among the atypical agents clozapine and olanzepine were shown to have the biggest average increases in weight, at 3.99 kg and 3.51 kg respectively. The conventional agent associated with the least amount of weight gain was molindone which showed on average a 0.81 kg decrease in weight after ten weeks of therapy. The atypical agent that showed the lowest average increase in weight after ten weeks of therapy was ziprasadone, which showed an average increase in weight of only 0.04 kg. (Allison)
In a study by ganguli et al 50 patients on olanzapine were compared with 50 patients on risperidone. Following 4 months or treatment, 36% of the olanzapine group had gained weight in excess of 2 kg of weight, while only 20% of the risperidone group saw levels of weight gain that high.
In a small study conducted by Megna and Dewan average increases in weight were found to be less than 5 kg in patients with schizophrenia who were maintained on risperidone for a period of 16 months. Tendon, et al report average weight gains at one year post initiation of therapy that range from 33 lbs with clozapine, and 25 lbs with olanzapine, to 4-8 lbs with risperidone and quetiapine, to 2 lbs with aripiprazole and ziprazodone.
For now it follows that the relative risk of weight gain associated with the use of atypical antipsychotics appears to be clozapine > olanzapine > quetiapine = risperidone > ziprasodone = aripiprazole. However as time goes on and our experience with the agents increases these assumptions may have to be reevaluated.
Lipids
Hypercholesterolemia and hypertriglyceridemia are also documented risk factors for cardiovascular disease. Increased rates of LDL, total cholesterol and triglycride levels have been reported in patients on antipsychotics.
In the study comparing treatment with haloperidol, clozapine, olanzapine and risperidone, both the clozapine and olanzapine treated groups had a significant increase in total cholesterol eight weeks after therapy was initiatied (lindenamyer). The clozapine group saw an average increase in total cholesterol of 14.7 mg/dL above baseline, while the olanzapine group saw an average increase of 12.3 mg/dl above baseline. There were no significant changes in choleseterol levels in either the haloperidol group or the risperidone group.
A study comparing triglyceride levels after treatment of 222 patients with haloperidol or clozapine showed an association between clozapine use and increased levels of triglycerides in men. Baseline triglyceride levels increased an average of 48.13% in men treated with clozapine. By comparison, men in the study treated with haloperidol showed an average decrease in baseline triglyceride levels of 17.23% after similar period of treatment. Women in both the haloperidol and clozapine groups saw increases in baselign triglyceride levels at an average of 50.51% and 35.38% respectively. (Gaulin)
While the benefits these medications have offered are great, like all medications, the atypical antipsychotics are not without side effects. Just as the atypical agents can be grouped together based on their similar spectrum of symptom coverage and lack of EPS/TD related side effects, they can be grouped together based on their tendency to each cause other similar side effects. Perhaps the most publicized of the side effects that widespread use of these agents has shown are the effects they have had on metabolism, most noteably their tendency
The first medications to treat schizophrenia were introduced in the 1950s. While these early, or “conventional” antipsychotics have been very effective at treating the positive symptoms of the disease, they also tend to cause devastating extrapyramidal motor symptom side effects (EPS) and often irreversible tardive dyskinesia (TD). The symptoms of EPS mimic that of Parkinson’s Disease and include things such as tremor, akathisia, and acute dystonia. TD causes uncontrollable facial and tongue movements like chewing and grimacing and hyperkinetic activity in the distal extremities.
Treatment with pharmaceutical agents like haloperidol, thioridazine, or chlorpromazine control the psychotic aspects of schizophrenia by blocking dopamine type 2 (D2) receptors in the mesolimbic pathway in the brain (402). Unfortunately there are also D2 receptors in other areas of the brain, specifically the substantia nigra and basal ganlia that these agents will block as well which initially cause EPS. With chronic blockade of D2 receptors in the nigrostriatal pathway, EPS will progress to TD at a rate of 4% per year of exposure to the antipsychotic agent.
The development of movement related side effects further increase the social stigma that schizophrenic patients face, making it very difficult to encourage patients to remain compliant with these agents for any length of time. Once patients discontinue treatment psychosis will typically relapse at a rate of approximately 10% per month, so that 50% or more have relapsed by 6 months after the medication is discontinued. (408)
In 1990, clozapine, the first of the new or “atypical” antipsychotics was approved by the FDA for the treatment of schizophrenia. The new agents were given the title of “atypical” because of their similar clinical properties, most noteably their low rates of EPS and efficacy for treating negative symptoms of schizophrenia. Pharmacologically speaking, the medications in this class have chemical structures that are very different from one another, howver they all act on the same receptors in the brain.
Like their conventional counterparts, the atypicals treat the positive symptoms of schizophrenia by blocking D2 receptors. In addition to D2 receptor blockade, the atypicals block serontonin 2A (5HT2A) receptors as well, which helps to explain why these agents are also effective at treating the negative, cognitive, and affective symptoms of schizophrenia. (416)
This antagonism of the 5HT2A receptors in the nigrastriatal pathways of the brain is also thought to be responsible for the relative lack of EPS seen with the atypical agents. 5HT2A antagonism in the nigrostraital pathway leads to the reversal of D2 receptor blockade in the area and blocking 5HT2A receptors also stimulates the release of dopamine in the nigrostriatial pathway. With an increase presence of dopamine in the substansia nigra, the extrapyramidal side effects are virtually eliminated. (417).
As a class, the atypical antipsychotics, have virtually taken over the treatment of schizophrenia, and account for approximately 80% of all antipsychotics prescribed in the United States. (Tandon) There are currently six atypical antipsychotics approved for use in the United States- clozapine (Clozaril), olanzapine (Zyprexa), qutiapine (Seroquel), risperidone (Risperdal), zisprazadone (Geodon), and aripiprazole (Abilify). Clozapine remains the most effect agent available for treating all four dimensions of schizophrenia symptoms. However, it has been associated with agranulocytosis, a rare but life threatening side effect, so its use is reserved for treatment resistant patients.
As experience with the atypical antipsychotics grows, other similarities amongst the different drugs in the class are becoming evident as well. Perhaps the most other most notable similarity with these agents are the metabolic disturbances that often arise in patients that take them. Increased rates of type 2 diabetes, hyperlipidemia, and obesity have all been associated with atypical antipsychotic treatment.
Diabetes:
Type 2 diabetes is a serious health problem in the United States. In 2002 the CDC estimated that approximately 6.3% of the population, or 18.2 million Americans suffer from the disease, and 90% of those have type 2 diabetes (CDC). People with diabetes have a risk of developing heart disease that is 2-4 times greater than that of the general population and diabetes is currently the sixth leading cause of death in the United States (CDC).
Schizophrenia itself appears to carry an increased risk of diabetes unrelated to treatment with antipsychotics. A study of first episode, drug-naïve schizophrenia patients found high rates impaired glucose metabolism, a precursor for the development of type 2 diabetes. Impaired fasting glucose tolerance was observed in 15.4% of the patients with schizophrenia, compared to none of the matched healthy comparison subjects (sas).
Use of antipsychotic medication also appears to increase the risks of developing type 2 diabetes. Rates of diabetes have been found to be higher in patients treated with both typical and atypical antipsychotics than in the general population. A retrospective analysis of more than 56,000 patients treated with antipsychotics (both conventional and atypical) estimated the annual incidence rate of diabetes to be 4.4%, a rate considerably higher than the expected 6.3 cases per 1000 people annually the general U.S. population. (lelise).
The risks may be even greater for younger patients treated with antipsychotic medication. The rate of diabetes for people between the ages of 20-39 in the general U.S. population is 1.1%. Rates of diabetes between 6.2-8.7% were observed in a retrospective analysis of more than 4000 people between the ages of 20-39 who received treatment with a conventional or atypical agent. (sernyak)
There is also evidence available to suggest that the use of atypical agents may be associated with a higher rate of diabetes compared to the use of conventional agents. After controlling for the effects of age, a retrospective comparison of 38,632 patients on antispcychotic therapy: 15,984 on conventional agents and 22,648 on atypical agents, found that paitents who received atypical neuroleptics were 9% more likey to have diabetes than those who receivd conventional agents. (sernyak)
Among the atypical agents, clozapine and olanzapine appear to carry the greatest risk of causing abnormalities in glucose metabolism. At the end of a 5 year study of 82 patients being treated with clozapine, 30 (36.6%) were found to have been diagnosed with type 2 diabetes (Henderson). Another study involving almost 6000 patients using either olanzepine or risperidone found that the risk of developing diabetes was 37% higher in the patients treated with olanzepine. (Medscape).
At current time it appears that the two most recently approved antipsychotics, ziprasadone and aripiprazole, carry the lowest risk for developing diabetes of all the atypical agents (something). Use of quetiapine and risperidone appear to carry a greater risk of diabetes than ziprazpdone or aripiprazole, but less than clozapine and olanzepine. Experience with clozapine and olanzepine is still greater than experience with any of the other atypical agents. Because of this fact it’s reasonable to believe that as time goes on, different conclusions may be reached on the relative propensity to cause diabetes among the atypical antipsychotics.
Weight Gain:
Obesity is a growing epidemic in the United States with almost two-thirds of the population being classified as overweight (BMI > 25 kg/M2), and obesity itself is a well established cause of type 2 diabetes (cdc). There are also well established risk factors that put an individual at an increased risk for being overweight. These risk factors include things like smoking, sedentary lifestyle, and poor diet as a result of lower socio-economic class. In general these risk factors are common among patients with psychiatric illnesses (Sachthansknsa).
Although data is limited, there is some evidence to suggest that the rate of obesity in patients with schizophrenia and affective disorders in medication naïve patients is approximately 1.5-2 times higher than that of the general population. (ADA). There is greater evidence to suggest that treatment with an antipsychotic, whether it is conventional or atypical, results in significant weight gain. Published reports show that as many as 50% of patients will show substantial increases in weight with long term antipsychotic treatment (Sathay). The relative frequency with which weight gain occurs seems to vary with each drug.
Allison, et al preformed a meta-analysis on published reports of changes in weight occurring ten weeks after the initiation of therapy with a neuroleptic. Their findings showed that almost all of the commercially available antipsychotics, regardless of whether they are classified as convetional or atypical agents, cause some degree of weight gain when compared to a placebo. Thioridazine and chlorpromazine were the conventional agents associated with the largest average degree of weight change, at 3.49 kg and 2.10 kg respectively. Among the atypical agents clozapine and olanzepine were shown to have the biggest average increases in weight, at 3.99 kg and 3.51 kg respectively. The conventional agent associated with the least amount of weight gain was molindone which showed on average a 0.81 kg decrease in weight after ten weeks of therapy. The atypical agent that showed the lowest average increase in weight after ten weeks of therapy was ziprasadone, which showed an average increase in weight of only 0.04 kg. (Allison)
In a study by ganguli et al 50 patients on olanzapine were compared with 50 patients on risperidone. Following 4 months or treatment, 36% of the olanzapine group had gained weight in excess of 2 kg of weight, while only 20% of the risperidone group saw levels of weight gain that high.
In a small study conducted by Megna and Dewan average increases in weight were found to be less than 5 kg in patients with schizophrenia who were maintained on risperidone for a period of 16 months. Tendon, et al report average weight gains at one year post initiation of therapy that range from 33 lbs with clozapine, and 25 lbs with olanzapine, to 4-8 lbs with risperidone and quetiapine, to 2 lbs with aripiprazole and ziprazodone.
For now it follows that the relative risk of weight gain associated with the use of atypical antipsychotics appears to be clozapine > olanzapine > quetiapine = risperidone > ziprasodone = aripiprazole. However as time goes on and our experience with the agents increases these assumptions may have to be reevaluated.
Lipids
Hypercholesterolemia and hypertriglyceridemia are also documented risk factors for cardiovascular disease. Increased rates of LDL, total cholesterol and triglycride levels have been reported in patients on antipsychotics.
In the study comparing treatment with haloperidol, clozapine, olanzapine and risperidone, both the clozapine and olanzapine treated groups had a significant increase in total cholesterol eight weeks after therapy was initiatied (lindenamyer). The clozapine group saw an average increase in total cholesterol of 14.7 mg/dL above baseline, while the olanzapine group saw an average increase of 12.3 mg/dl above baseline. There were no significant changes in choleseterol levels in either the haloperidol group or the risperidone group.
A study comparing triglyceride levels after treatment of 222 patients with haloperidol or clozapine showed an association between clozapine use and increased levels of triglycerides in men. Baseline triglyceride levels increased an average of 48.13% in men treated with clozapine. By comparison, men in the study treated with haloperidol showed an average decrease in baseline triglyceride levels of 17.23% after similar period of treatment. Women in both the haloperidol and clozapine groups saw increases in baselign triglyceride levels at an average of 50.51% and 35.38% respectively. (Gaulin)
While the benefits these medications have offered are great, like all medications, the atypical antipsychotics are not without side effects. Just as the atypical agents can be grouped together based on their similar spectrum of symptom coverage and lack of EPS/TD related side effects, they can be grouped together based on their tendency to each cause other similar side effects. Perhaps the most publicized of the side effects that widespread use of these agents has shown are the effects they have had on metabolism, most noteably their tendency
Paper
Schizophrenia remains one of the most severe, chronic, and debilitating psychiatric disorders. Generally beginning in late adolescence or early adulthood, it effects approximately 1% of the population. The disease is characterized by a variety of symptoms along four dimensions: positive symptoms, negative symptoms, cognitive impairments, and disturbances in mood and affect. Life expectancy….
The first medications to treat schizophrenia were introduced in the 1950s. While these early, or “conventional” antipsychotics have been very effective at treating the positive symptoms of the disease, they also tend to cause devastating extrapyramidal motor symptom side effects (EPS) and often irreversible tardive dyskinesia (TD). The symptoms of EPS mimic that of Parkinson’s Disease and include things such as tremor, akathisia, and acute dystonia. TD causes uncontrollable facial and tongue movements like chewing and grimacing and hyperkinetic activity in the distal extremities.
Treatment with pharmaceutical agents like haloperidol, thioridazine, or chlorpromazine control the psychotic aspects of schizophrenia by blocking dopamine type 2 (D2) receptors in the mesolimbic pathway in the brain (402). Unfortunately there are also D2 receptors in other areas of the brain, specifically the substantia nigra and basal ganlia that these agents will block as well which initially cause EPS. With chronic blockade of D2 receptors in the nigrostriatal pathway, EPS will progress to TD at a rate of 4% per year of exposure to the antipsychotic agent.
The development of movement related side effects further increase the social stigma that schizophrenic patients face, making it very difficult to encourage patients to remain compliant with these agents for any length of time. Once patients discontinue treatment psychosis will typically relapse at a rate of approximately 10% per month, so that 50% or more have relapsed by 6 months after the medication is discontinued. (408)
In 1990, clozapine, the first of the new or “atypical” antipsychotics was approved by the FDA for the treatment of schizophrenia. The new agents were given the title of “atypical” because of their similar clinical properties, most noteably their low rates of EPS and efficacy for treating negative symptoms of schizophrenia. Pharmacologically speaking, the medications in this class have chemical structures that are very different from one another, howver they all act on the same receptors in the brain.
Like their conventional counterparts, the atypicals treat the positive symptoms of schizophrenia by blocking D2 receptors. In addition to D2 receptor blockade, the atypicals block serontonin 2A (5HT2A) receptors as well, which helps to explain why these agents are also effective at treating the negative, cognitive, and affective symptoms of schizophrenia. (416)
This antagonism of the 5HT2A receptors in the nigrastriatal pathways of the brain is also thought to be responsible for the relative lack of EPS seen with the atypical agents. 5HT2A antagonism in the nigrostraital pathway leads to the reversal of D2 receptor blockade in the area and blocking 5HT2A receptors also stimulates the release of dopamine in the nigrostriatial pathway. With an increase presence of dopamine in the substansia nigra, the extrapyramidal side effects are virtually eliminated. (417).
As a class, the atypical antipsychotics, have virtually taken over the treatment of schizophrenia, and account for approximately 80% of all antipsychotics prescribed in the United States. (Tandon) There are currently six atypical antipsychotics approved for use in the United States- clozapine (Clozaril), olanzapine (Zyprexa), qutiapine (Seroquel), risperidone (Risperdal), zisprazadone (Geodon), and aripiprazole (Abilify). Clozapine remains the most effect agent available for treating all four dimensions of schizophrenia symptoms. However, it has been associated with agranulocytosis, a rare but life threatening side effect, so its use is reserved for treatment resistant patients.
As experience with the atypical antipsychotics grows, other similarities amongst the different drugs in the class are becoming evident as well. Perhaps the most other most notable similarity with these agents are the metabolic disturbances that often arise in patients that take them. Increased rates of type 2 diabetes, hyperlipidemia, and obesity have all been associated with atypical antipsychotic treatment.
Diabetes:
Type 2 diabetes is a serious health problem in the United States. In 2002 the CDC estimated that approximately 6.3% of the population, or 18.2 million Americans suffer from the disease, and 90% of those have type 2 diabetes (CDC). People with diabetes have a risk of developing heart disease that is 2-4 times greater than that of the general population and diabetes is currently the sixth leading cause of death in the United States (CDC).
Schizophrenia itself appears to carry an increased risk of diabetes unrelated to treatment with antipsychotics. A study of first episode, drug-naïve schizophrenia patients found high rates impaired glucose metabolism, a precursor for the development of type 2 diabetes. Impaired fasting glucose tolerance was observed in 15.4% of the patients with schizophrenia, compared to none of the matched healthy comparison subjects (sas).
Use of antipsychotic medication also appears to increase the risks of developing type 2 diabetes. Rates of diabetes have been found to be higher in patients treated with both typical and atypical antipsychotics than in the general population. A retrospective analysis of more than 56,000 patients treated with antipsychotics (both conventional and atypical) estimated the annual incidence rate of diabetes to be 4.4%, a rate considerably higher than the expected 6.3 cases per 1000 people annually the general U.S. population. (lelise).
The risks may be even greater for younger patients treated with antipsychotic medication. The rate of diabetes for people between the ages of 20-39 in the general U.S. population is 1.1%. Rates of diabetes between 6.2-8.7% were observed in a retrospective analysis of more than 4000 people between the ages of 20-39 who received treatment with a conventional or atypical agent. (sernyak)
There is also evidence available to suggest that the use of atypical agents may be associated with a higher rate of diabetes compared to the use of conventional agents. After controlling for the effects of age, a retrospective comparison of 38,632 patients on antispcychotic therapy: 15,984 on conventional agents and 22,648 on atypical agents, found that paitents who received atypical neuroleptics were 9% more likey to have diabetes than those who receivd conventional agents. (sernyak)
Among the atypical agents, clozapine and olanzapine appear to carry the greatest risk of causing abnormalities in glucose metabolism. At the end of a 5 year study of 82 patients being treated with clozapine, 30 (36.6%) were found to have been diagnosed with type 2 diabetes (Henderson). Another study involving almost 6000 patients using either olanzepine or risperidone found that the risk of developing diabetes was 37% higher in the patients treated with olanzepine. (Medscape).
At current time it appears that the two most recently approved antipsychotics, ziprasadone and aripiprazole, carry the lowest risk for developing diabetes of all the atypical agents (something). Use of quetiapine and risperidone appear to carry a greater risk of diabetes than ziprazpdone or aripiprazole, but less than clozapine and olanzepine. Experience with clozapine and olanzepine is still greater than experience with any of the other atypical agents. Because of this fact it’s reasonable to believe that as time goes on, different conclusions may be reached on the relative propensity to cause diabetes among the atypical antipsychotics.
Weight Gain:
Obesity is a growing epidemic in the United States with almost two-thirds of the population being classified as overweight (BMI > 25 kg/M2), and obesity itself is a well established cause of type 2 diabetes (cdc). There are also well established risk factors that put an individual at an increased risk for being overweight. These risk factors include things like smoking, sedentary lifestyle, and poor diet as a result of lower socio-economic class. In general these risk factors are common among patients with psychiatric illnesses (Sachthansknsa).
Although data is limited, there is some evidence to suggest that the rate of obesity in patients with schizophrenia and affective disorders in medication naïve patients is approximately 1.5-2 times higher than that of the general population. (ADA). There is greater evidence to suggest that treatment with an antipsychotic, whether it is conventional or atypical, results in significant weight gain. Published reports show that as many as 50% of patients will show substantial increases in weight with long term antipsychotic treatment (Sathay). The relative frequency with which weight gain occurs seems to vary with each drug.
Allison, et al preformed a meta-analysis on published reports of changes in weight occurring ten weeks after the initiation of therapy with a neuroleptic. Their findings showed that almost all of the commercially available antipsychotics, regardless of whether they are classified as convetional or atypical agents, cause some degree of weight gain when compared to a placebo. Thioridazine and chlorpromazine were the conventional agents associated with the largest average degree of weight change, at 3.49 kg and 2.10 kg respectively. Among the atypical agents clozapine and olanzepine were shown to have the biggest average increases in weight, at 3.99 kg and 3.51 kg respectively. The conventional agent associated with the least amount of weight gain was molindone which showed on average a 0.81 kg decrease in weight after ten weeks of therapy. The atypical agent that showed the lowest average increase in weight after ten weeks of therapy was ziprasadone, which showed an average increase in weight of only 0.04 kg. (Allison)
In a study by ganguli et al 50 patients on olanzapine were compared with 50 patients on risperidone. Following 4 months or treatment, 36% of the olanzapine group had gained weight in excess of 2 kg of weight, while only 20% of the risperidone group saw levels of weight gain that high.
In a small study conducted by Megna and Dewan average increases in weight were found to be less than 5 kg in patients with schizophrenia who were maintained on risperidone for a period of 16 months. Tendon, et al report average weight gains at one year post initiation of therapy that range from 33 lbs with clozapine, and 25 lbs with olanzapine, to 4-8 lbs with risperidone and quetiapine, to 2 lbs with aripiprazole and ziprazodone.
For now it follows that the relative risk of weight gain associated with the use of atypical antipsychotics appears to be clozapine > olanzapine > quetiapine = risperidone > ziprasodone = aripiprazole. However as time goes on and our experience with the agents increases these assumptions may have to be reevaluated.
Lipids
Hypercholesterolemia and hypertriglyceridemia are also documented risk factors for cardiovascular disease. Increased rates of LDL, total cholesterol and triglycride levels have been reported in patients on antipsychotics.
In the study comparing treatment with haloperidol, clozapine, olanzapine and risperidone, both the clozapine and olanzapine treated groups had a significant increase in total cholesterol eight weeks after therapy was initiatied (lindenamyer). The clozapine group saw an average increase in total cholesterol of 14.7 mg/dL above baseline, while the olanzapine group saw an average increase of 12.3 mg/dl above baseline. There were no significant changes in choleseterol levels in either the haloperidol group or the risperidone group.
A study comparing triglyceride levels after treatment of 222 patients with haloperidol or clozapine showed an association between clozapine use and increased levels of triglycerides in men. Baseline triglyceride levels increased an average of 48.13% in men treated with clozapine. By comparison, men in the study treated with haloperidol showed an average decrease in baseline triglyceride levels of 17.23% after similar period of treatment. Women in both the haloperidol and clozapine groups saw increases in baselign triglyceride levels at an average of 50.51% and 35.38% respectively. (Gaulin)
While the benefits these medications have offered are great, like all medications, the atypical antipsychotics are not without side effects. Just as the atypical agents can be grouped together based on their similar spectrum of symptom coverage and lack of EPS/TD related side effects, they can be grouped together based on their tendency to each cause other similar side effects. Perhaps the most publicized of the side effects that widespread use of these agents has shown are the effects they have had on metabolism, most noteably their tendency
The first medications to treat schizophrenia were introduced in the 1950s. While these early, or “conventional” antipsychotics have been very effective at treating the positive symptoms of the disease, they also tend to cause devastating extrapyramidal motor symptom side effects (EPS) and often irreversible tardive dyskinesia (TD). The symptoms of EPS mimic that of Parkinson’s Disease and include things such as tremor, akathisia, and acute dystonia. TD causes uncontrollable facial and tongue movements like chewing and grimacing and hyperkinetic activity in the distal extremities.
Treatment with pharmaceutical agents like haloperidol, thioridazine, or chlorpromazine control the psychotic aspects of schizophrenia by blocking dopamine type 2 (D2) receptors in the mesolimbic pathway in the brain (402). Unfortunately there are also D2 receptors in other areas of the brain, specifically the substantia nigra and basal ganlia that these agents will block as well which initially cause EPS. With chronic blockade of D2 receptors in the nigrostriatal pathway, EPS will progress to TD at a rate of 4% per year of exposure to the antipsychotic agent.
The development of movement related side effects further increase the social stigma that schizophrenic patients face, making it very difficult to encourage patients to remain compliant with these agents for any length of time. Once patients discontinue treatment psychosis will typically relapse at a rate of approximately 10% per month, so that 50% or more have relapsed by 6 months after the medication is discontinued. (408)
In 1990, clozapine, the first of the new or “atypical” antipsychotics was approved by the FDA for the treatment of schizophrenia. The new agents were given the title of “atypical” because of their similar clinical properties, most noteably their low rates of EPS and efficacy for treating negative symptoms of schizophrenia. Pharmacologically speaking, the medications in this class have chemical structures that are very different from one another, howver they all act on the same receptors in the brain.
Like their conventional counterparts, the atypicals treat the positive symptoms of schizophrenia by blocking D2 receptors. In addition to D2 receptor blockade, the atypicals block serontonin 2A (5HT2A) receptors as well, which helps to explain why these agents are also effective at treating the negative, cognitive, and affective symptoms of schizophrenia. (416)
This antagonism of the 5HT2A receptors in the nigrastriatal pathways of the brain is also thought to be responsible for the relative lack of EPS seen with the atypical agents. 5HT2A antagonism in the nigrostraital pathway leads to the reversal of D2 receptor blockade in the area and blocking 5HT2A receptors also stimulates the release of dopamine in the nigrostriatial pathway. With an increase presence of dopamine in the substansia nigra, the extrapyramidal side effects are virtually eliminated. (417).
As a class, the atypical antipsychotics, have virtually taken over the treatment of schizophrenia, and account for approximately 80% of all antipsychotics prescribed in the United States. (Tandon) There are currently six atypical antipsychotics approved for use in the United States- clozapine (Clozaril), olanzapine (Zyprexa), qutiapine (Seroquel), risperidone (Risperdal), zisprazadone (Geodon), and aripiprazole (Abilify). Clozapine remains the most effect agent available for treating all four dimensions of schizophrenia symptoms. However, it has been associated with agranulocytosis, a rare but life threatening side effect, so its use is reserved for treatment resistant patients.
As experience with the atypical antipsychotics grows, other similarities amongst the different drugs in the class are becoming evident as well. Perhaps the most other most notable similarity with these agents are the metabolic disturbances that often arise in patients that take them. Increased rates of type 2 diabetes, hyperlipidemia, and obesity have all been associated with atypical antipsychotic treatment.
Diabetes:
Type 2 diabetes is a serious health problem in the United States. In 2002 the CDC estimated that approximately 6.3% of the population, or 18.2 million Americans suffer from the disease, and 90% of those have type 2 diabetes (CDC). People with diabetes have a risk of developing heart disease that is 2-4 times greater than that of the general population and diabetes is currently the sixth leading cause of death in the United States (CDC).
Schizophrenia itself appears to carry an increased risk of diabetes unrelated to treatment with antipsychotics. A study of first episode, drug-naïve schizophrenia patients found high rates impaired glucose metabolism, a precursor for the development of type 2 diabetes. Impaired fasting glucose tolerance was observed in 15.4% of the patients with schizophrenia, compared to none of the matched healthy comparison subjects (sas).
Use of antipsychotic medication also appears to increase the risks of developing type 2 diabetes. Rates of diabetes have been found to be higher in patients treated with both typical and atypical antipsychotics than in the general population. A retrospective analysis of more than 56,000 patients treated with antipsychotics (both conventional and atypical) estimated the annual incidence rate of diabetes to be 4.4%, a rate considerably higher than the expected 6.3 cases per 1000 people annually the general U.S. population. (lelise).
The risks may be even greater for younger patients treated with antipsychotic medication. The rate of diabetes for people between the ages of 20-39 in the general U.S. population is 1.1%. Rates of diabetes between 6.2-8.7% were observed in a retrospective analysis of more than 4000 people between the ages of 20-39 who received treatment with a conventional or atypical agent. (sernyak)
There is also evidence available to suggest that the use of atypical agents may be associated with a higher rate of diabetes compared to the use of conventional agents. After controlling for the effects of age, a retrospective comparison of 38,632 patients on antispcychotic therapy: 15,984 on conventional agents and 22,648 on atypical agents, found that paitents who received atypical neuroleptics were 9% more likey to have diabetes than those who receivd conventional agents. (sernyak)
Among the atypical agents, clozapine and olanzapine appear to carry the greatest risk of causing abnormalities in glucose metabolism. At the end of a 5 year study of 82 patients being treated with clozapine, 30 (36.6%) were found to have been diagnosed with type 2 diabetes (Henderson). Another study involving almost 6000 patients using either olanzepine or risperidone found that the risk of developing diabetes was 37% higher in the patients treated with olanzepine. (Medscape).
At current time it appears that the two most recently approved antipsychotics, ziprasadone and aripiprazole, carry the lowest risk for developing diabetes of all the atypical agents (something). Use of quetiapine and risperidone appear to carry a greater risk of diabetes than ziprazpdone or aripiprazole, but less than clozapine and olanzepine. Experience with clozapine and olanzepine is still greater than experience with any of the other atypical agents. Because of this fact it’s reasonable to believe that as time goes on, different conclusions may be reached on the relative propensity to cause diabetes among the atypical antipsychotics.
Weight Gain:
Obesity is a growing epidemic in the United States with almost two-thirds of the population being classified as overweight (BMI > 25 kg/M2), and obesity itself is a well established cause of type 2 diabetes (cdc). There are also well established risk factors that put an individual at an increased risk for being overweight. These risk factors include things like smoking, sedentary lifestyle, and poor diet as a result of lower socio-economic class. In general these risk factors are common among patients with psychiatric illnesses (Sachthansknsa).
Although data is limited, there is some evidence to suggest that the rate of obesity in patients with schizophrenia and affective disorders in medication naïve patients is approximately 1.5-2 times higher than that of the general population. (ADA). There is greater evidence to suggest that treatment with an antipsychotic, whether it is conventional or atypical, results in significant weight gain. Published reports show that as many as 50% of patients will show substantial increases in weight with long term antipsychotic treatment (Sathay). The relative frequency with which weight gain occurs seems to vary with each drug.
Allison, et al preformed a meta-analysis on published reports of changes in weight occurring ten weeks after the initiation of therapy with a neuroleptic. Their findings showed that almost all of the commercially available antipsychotics, regardless of whether they are classified as convetional or atypical agents, cause some degree of weight gain when compared to a placebo. Thioridazine and chlorpromazine were the conventional agents associated with the largest average degree of weight change, at 3.49 kg and 2.10 kg respectively. Among the atypical agents clozapine and olanzepine were shown to have the biggest average increases in weight, at 3.99 kg and 3.51 kg respectively. The conventional agent associated with the least amount of weight gain was molindone which showed on average a 0.81 kg decrease in weight after ten weeks of therapy. The atypical agent that showed the lowest average increase in weight after ten weeks of therapy was ziprasadone, which showed an average increase in weight of only 0.04 kg. (Allison)
In a study by ganguli et al 50 patients on olanzapine were compared with 50 patients on risperidone. Following 4 months or treatment, 36% of the olanzapine group had gained weight in excess of 2 kg of weight, while only 20% of the risperidone group saw levels of weight gain that high.
In a small study conducted by Megna and Dewan average increases in weight were found to be less than 5 kg in patients with schizophrenia who were maintained on risperidone for a period of 16 months. Tendon, et al report average weight gains at one year post initiation of therapy that range from 33 lbs with clozapine, and 25 lbs with olanzapine, to 4-8 lbs with risperidone and quetiapine, to 2 lbs with aripiprazole and ziprazodone.
For now it follows that the relative risk of weight gain associated with the use of atypical antipsychotics appears to be clozapine > olanzapine > quetiapine = risperidone > ziprasodone = aripiprazole. However as time goes on and our experience with the agents increases these assumptions may have to be reevaluated.
Lipids
Hypercholesterolemia and hypertriglyceridemia are also documented risk factors for cardiovascular disease. Increased rates of LDL, total cholesterol and triglycride levels have been reported in patients on antipsychotics.
In the study comparing treatment with haloperidol, clozapine, olanzapine and risperidone, both the clozapine and olanzapine treated groups had a significant increase in total cholesterol eight weeks after therapy was initiatied (lindenamyer). The clozapine group saw an average increase in total cholesterol of 14.7 mg/dL above baseline, while the olanzapine group saw an average increase of 12.3 mg/dl above baseline. There were no significant changes in choleseterol levels in either the haloperidol group or the risperidone group.
A study comparing triglyceride levels after treatment of 222 patients with haloperidol or clozapine showed an association between clozapine use and increased levels of triglycerides in men. Baseline triglyceride levels increased an average of 48.13% in men treated with clozapine. By comparison, men in the study treated with haloperidol showed an average decrease in baseline triglyceride levels of 17.23% after similar period of treatment. Women in both the haloperidol and clozapine groups saw increases in baselign triglyceride levels at an average of 50.51% and 35.38% respectively. (Gaulin)
While the benefits these medications have offered are great, like all medications, the atypical antipsychotics are not without side effects. Just as the atypical agents can be grouped together based on their similar spectrum of symptom coverage and lack of EPS/TD related side effects, they can be grouped together based on their tendency to each cause other similar side effects. Perhaps the most publicized of the side effects that widespread use of these agents has shown are the effects they have had on metabolism, most noteably their tendency
Friday, March 11, 2005
Atypical Antipsychotics
Schizophrenia remains one of the most severe, chronic, and debilitating psychiatric disorders. It generally begins in late adolescence or early adulthood and effects approximately 1% of the population. The disease is characterized by a variety of symptoms along four dimensions: positive symptoms, negative symptoms, cognitive impairments, and disturbances in mood and affect.
The first medications to treat schizophrenia were introduced in the 1950s. While these early, or “conventional” antipsychotics are very effective at treating the positive symptoms of the disease, they also tend to cause devastating, and often irreversible extrapyramidal side effects.
The first medications to treat schizophrenia were introduced in the 1950s. While these early, or “conventional” antipsychotics are very effective at treating the positive symptoms of the disease, they also tend to cause devastating, and often irreversible extrapyramidal side effects.
Sunday, December 14, 2003
Questions Regarding the Influenza Outbreak
Because of the abnormaly high number of influenza cases being reported so early in the flu season, & the fact that the first population group to be largely infected were children (over age 5) in Texas, do you believe that there is any reason to think that the so-called "nasal" vaccine may have actually contributed to the outbreak? This is the first year that the nasal vaccine has been available, it is made from a live virus. Those receiving it can potentionally pass the virus on to others which can then cause an actual full-blown viral infection in others. In light of those facts, it seems more than coincedental that the same year this vaccine was introduced, there are pandemic levels of influenza cases & deaths being reported so abnormally early in the sesason. The fact that the intial outbreak can be traced to children can provide more evidence that the nasal vaccine may be a contributing factor to the outbreak. The nasal vaccine is approved for healthy children greater than 5 years old (the same population the outbreak began in), & it is children who typically would be afraid of receiving a shot & would utilize a less painful option when it was available.
Tuesday, November 18, 2003
Physicians Need to SERIOUSLY Examine They're Prescribing Habits
These are some things that I see happen everyday when I'm at work as a retail pharmacist. To me, they are examples of appalling misuse of expensive medications when cheaper alternatives are available and would work just as well. It is obvious that doctors are prescribing based on what drug rep has been in their office lately or what new commericial they have seen on TV. Medical costs keep rising and the U.S. Healthcare system is in a serious crisis. Things like this NEED to change if we are ever going to get the ever going to get a control on health care spending so that it becomes affordable once again for everyone.
1. Seroquel, Zyprexa, and Risperdal are ATYPICAL ANTIPSYCHOTICS. They were developed to treat serious mental illnesses such as schizophrenia and bipolar disorder. They have some use in things like Obsessive Compulsive Disorder and Refractive Major Depressive Disorder. They are pretty much medications who's prescribing should be reserved for psychiatrists only. A general practioner is not seeing any of these conditions and if they are, they should be at least CONSULTING a psychiatrist. These medications cost between $300 and $700 a month (and that is the WHOLESALE cost, the cost to patients in more, not much because most pharmacies make little profit on these expensive medications). These medications are not first line sleep agents, they are not first line anxiolytics, they are not first line unipolar depression medications, they are not first line OCD medications. Why would ANYONE with a lick of common sense start someone on 25 mg of Seroquel at night to help them sleep, in the absence of one of the above mentioned appropriate uses for these drugs? How about trying a medication that is indicated for insomnia? Benadryl is cheap and non-habit forming, although some of the side effects are undesirable and need to be avoided in some people. Trazodone is a generic medication that has been used SUCCESSFULLY for decades and has been shown to help people restore a normal sleep pattern when it is used. It is also non-habit forming and carries little risk for side effects (except for rare cases of priapism in some men). Ambien and Sonota are two new sleep aids, but they are really only to be used for 7-10 days and are expensive. Benzodiazepines also can help with sleep and are cheap although they pose a large risk of creating drug dependecy with their extended use (so do Ambien and Sonota). Let's compare though a 30 day supply of the following therapies:
#30 Seroquel 25mg (NOT INDICATED FOR INSOMNIA)...................,...............$80 a month
#30 Zyprexa 5mg (NOT INDICATED FOR INSOMNIA)......................................$400 a month
#30 Ambien 10mg (NOT INDICATED FOR USE BEYOND 7-10 DAYS)................$80 a month
#30 Sonata 10mg (NOT INDICATED FOR USED BEYOND 7-10 DAYS)..............$75 a month
#30 Trazodone 100mg...................................................................................$10 a month
#30 Benadryl 25mg........................................................................................$5 a month
#30 Clonazepam 0.5mg................................................................................ $10 a month
Seems like a pretty obvious choice to me. And yet EVERYDAY I have prescriptions called in for Zyprexa and Seroquel and the like for patients who have never tried anything else for sleep and have no indications for using an atypical antipsychotic agent. They are using them soley for their side effect of somnolence. What a waste of money. I mean they could at least TRY a cheaped agent first!
2. Actiq is a immediate release narcotic medication. The medication is Fentanyl and it comes in a lollypop that patients suck on to get immediate pain relief. It is strong, HIGHLY addictive and HIGHLY abused. It is indicated for people with SERIOUS pain (mainly those who are DYING) who need IMMIDIATE pain relief and can no longer get enough relief from other methods of medication delivery (normal tablets, liquids, injections, etc.). The shorter acting a drug is, the more abuse potential it posesses. Unless it is being prescribed for a terminal patient, this medication should NOT be dispensed in an outpatient setting. There is ABSOLUTELY no reason to start an otherwise healthy middle aged adult with fibromyalgia on Actiq. Doctors do it though. A patient who has ONLY taken methadone to try and control her "fibromyalgia pain" is put on Actiq. In addition to all the other drawbacks of the medication, it's easy to overdose and die on narcotics (they simply stop people from breathing at levels not much beyond levels that effectively control pain), and they are EXPENSIVE. #5 Actiq 200mcg lollipops cost over $300. A patient like the above mentioned fibromyalgia patient should at least be tried on other narcotics before going to Actiq. I mean if we're going to use highly addictive pain meds, why not go with cheaper ones? Something even somkething like the highly addictive and very expensive Oxycontin would be much cheaper compared to Actiq. Percocet is generically available and can cost less than $20 a month. #6 Demerol injections cost about $10. Where is the logic in prescribing a medication like Actiq? Practice like this should be condemned!
I have more, but this is enough for tonight.
1. Seroquel, Zyprexa, and Risperdal are ATYPICAL ANTIPSYCHOTICS. They were developed to treat serious mental illnesses such as schizophrenia and bipolar disorder. They have some use in things like Obsessive Compulsive Disorder and Refractive Major Depressive Disorder. They are pretty much medications who's prescribing should be reserved for psychiatrists only. A general practioner is not seeing any of these conditions and if they are, they should be at least CONSULTING a psychiatrist. These medications cost between $300 and $700 a month (and that is the WHOLESALE cost, the cost to patients in more, not much because most pharmacies make little profit on these expensive medications). These medications are not first line sleep agents, they are not first line anxiolytics, they are not first line unipolar depression medications, they are not first line OCD medications. Why would ANYONE with a lick of common sense start someone on 25 mg of Seroquel at night to help them sleep, in the absence of one of the above mentioned appropriate uses for these drugs? How about trying a medication that is indicated for insomnia? Benadryl is cheap and non-habit forming, although some of the side effects are undesirable and need to be avoided in some people. Trazodone is a generic medication that has been used SUCCESSFULLY for decades and has been shown to help people restore a normal sleep pattern when it is used. It is also non-habit forming and carries little risk for side effects (except for rare cases of priapism in some men). Ambien and Sonota are two new sleep aids, but they are really only to be used for 7-10 days and are expensive. Benzodiazepines also can help with sleep and are cheap although they pose a large risk of creating drug dependecy with their extended use (so do Ambien and Sonota). Let's compare though a 30 day supply of the following therapies:
#30 Seroquel 25mg (NOT INDICATED FOR INSOMNIA)...................,...............$80 a month
#30 Zyprexa 5mg (NOT INDICATED FOR INSOMNIA)......................................$400 a month
#30 Ambien 10mg (NOT INDICATED FOR USE BEYOND 7-10 DAYS)................$80 a month
#30 Sonata 10mg (NOT INDICATED FOR USED BEYOND 7-10 DAYS)..............$75 a month
#30 Trazodone 100mg...................................................................................$10 a month
#30 Benadryl 25mg........................................................................................$5 a month
#30 Clonazepam 0.5mg................................................................................ $10 a month
Seems like a pretty obvious choice to me. And yet EVERYDAY I have prescriptions called in for Zyprexa and Seroquel and the like for patients who have never tried anything else for sleep and have no indications for using an atypical antipsychotic agent. They are using them soley for their side effect of somnolence. What a waste of money. I mean they could at least TRY a cheaped agent first!
2. Actiq is a immediate release narcotic medication. The medication is Fentanyl and it comes in a lollypop that patients suck on to get immediate pain relief. It is strong, HIGHLY addictive and HIGHLY abused. It is indicated for people with SERIOUS pain (mainly those who are DYING) who need IMMIDIATE pain relief and can no longer get enough relief from other methods of medication delivery (normal tablets, liquids, injections, etc.). The shorter acting a drug is, the more abuse potential it posesses. Unless it is being prescribed for a terminal patient, this medication should NOT be dispensed in an outpatient setting. There is ABSOLUTELY no reason to start an otherwise healthy middle aged adult with fibromyalgia on Actiq. Doctors do it though. A patient who has ONLY taken methadone to try and control her "fibromyalgia pain" is put on Actiq. In addition to all the other drawbacks of the medication, it's easy to overdose and die on narcotics (they simply stop people from breathing at levels not much beyond levels that effectively control pain), and they are EXPENSIVE. #5 Actiq 200mcg lollipops cost over $300. A patient like the above mentioned fibromyalgia patient should at least be tried on other narcotics before going to Actiq. I mean if we're going to use highly addictive pain meds, why not go with cheaper ones? Something even somkething like the highly addictive and very expensive Oxycontin would be much cheaper compared to Actiq. Percocet is generically available and can cost less than $20 a month. #6 Demerol injections cost about $10. Where is the logic in prescribing a medication like Actiq? Practice like this should be condemned!
I have more, but this is enough for tonight.
FluMist is a Danger to the Safety of America
Has anyone stopped to think about this?
We are in the midst of one of the earliest and most widespread influenze outbreaks in all of history. Two states are already reporting epidemic infection levels and it is only the 3rd week of November.
Interestingly enough, this is the first year that the nasal vaccine FluMist has been made available to the public.
FluMist is a LIVE VIRUS VACCINE, which means that it works to provide immunity by actually infecting people with a small amount of living flu virus. People who get FluMist inhale into their nasal passages a liquid that contains live and virulent influenza virus. Not only are they being infected, but by having the live virus in their nasal cavity and being exposed to the live virus, they can pass the living virus onto people around them. If they expose people who are advised to avoid getting FluMist (immunocompromised, people over 50, children under 5, etc.) they can potentially make them very ill, this will result in increased health care costs and spending, and possible deaths.
Because people have already received FluMist, there are people out there now spreading the live virus and possibly infecting people. It's not much of a stretch to think that we may have actually started the inlfuenza season early by intetionally giving people the virus.
DON'T PUT OTHERS AT RISK, SAY NO TO FLUMIST
We are in the midst of one of the earliest and most widespread influenze outbreaks in all of history. Two states are already reporting epidemic infection levels and it is only the 3rd week of November.
Interestingly enough, this is the first year that the nasal vaccine FluMist has been made available to the public.
FluMist is a LIVE VIRUS VACCINE, which means that it works to provide immunity by actually infecting people with a small amount of living flu virus. People who get FluMist inhale into their nasal passages a liquid that contains live and virulent influenza virus. Not only are they being infected, but by having the live virus in their nasal cavity and being exposed to the live virus, they can pass the living virus onto people around them. If they expose people who are advised to avoid getting FluMist (immunocompromised, people over 50, children under 5, etc.) they can potentially make them very ill, this will result in increased health care costs and spending, and possible deaths.
Because people have already received FluMist, there are people out there now spreading the live virus and possibly infecting people. It's not much of a stretch to think that we may have actually started the inlfuenza season early by intetionally giving people the virus.
DON'T PUT OTHERS AT RISK, SAY NO TO FLUMIST
Tuesday, October 28, 2003
Remeron is a Stupid Drug!!
Damn it! My error rate for the year just doubled today. I sent someone out with Remeron 30mg instead of Remeron 15mg. That drug is so easy to mess up because the quantity of 30 is often confused with the strength of 30. The good(?) thing is that I caught it right after the patient's case worker got out the door and got ahold of Steve H (RN) in time to stop it from getting to the patient, but I still look stupid.
The last time I fucked up was on a BLDC patient Why do I always mess them up? Steve et. al. have to think I'm a moron. Regardless, the difference between Remeron 15mg and Remeron 30mg is negligible both clinically and safety speaking. So it's not like a huge dangerous deal or anything, it just makes me look stupid, yet again. Why didn't I go to med school?
The last time I fucked up was on a BLDC patient Why do I always mess them up? Steve et. al. have to think I'm a moron. Regardless, the difference between Remeron 15mg and Remeron 30mg is negligible both clinically and safety speaking. So it's not like a huge dangerous deal or anything, it just makes me look stupid, yet again. Why didn't I go to med school?
Saturday, October 04, 2003
Dr. Seuss
I don't know who wrote this so I can't give them the credit they deserve. It's fantastic though!
Oh the things you can fill
For the folks who are ill.
With your bright shinny spatula
Oh, what a thrill.
Besmocked and bedecked out
In Pharmacist clothes
Knowing all of the things
That a Pharmacist Knows.
You're quick and efficient,
You're sharp and inventive,
It also just happens
You're anal rententive.
You read slips of paper
To get the specifics
From doctors who scribble out
Strange hieroglyphics.
Could it be Celebrex?
Or maybe Celexa
It might be a Z-Pak
Then it might be Zyprexa.
And you bill by computer
AWP
Minus 15 percent
Plus a buck twenty-three.
You fill and you bill
And you feel so dejected
'Cause half of your claims
Are being rejected.
So you pick up the phone
While computerized voices
Keep you waiting forever
Explaining the choices.
"Press 1 for directions,
Or maybe it's 2,
Push 'pound' for a message
It sucks to be you."
Then you pour at the pills
On your pill counting tray
And you count, and you count,
And you count pills all day.
And the customers gripe
And complain when you're fillin'
Could it be the whole world
Is on "Grouchacillin?"
"My pills are too big
And my co-pay's too high!
Take it four times a day?
I cannot comply!"
Then you scarf down your sandwich
In one single bite
Which if done in a restaurant
Would be impolite.
But a Doc's on line one
Mrs. Jones on line two
She has 500 pills
Will you cut them in two?
And the drug reps, they tap
On your counter, tap, tap,
To give you their spiel
Plus a load of free crap!
There's pens and there's post-its
There's free stuff galore
But the really cool clock's
For the doc who's next door.
Then ol' Mrs. Snifflemore
Gives you that smile
Any you know once again
That it's all been worthwhile.
So you hang up your smock,
And put down your free pen,
Tomorrow you'll do it
All over again.
Oh the things you will fill
For the folks who are ill.
With your bright shiny spatula
Oh, what a thrill.
Oh the things you can fill
For the folks who are ill.
With your bright shinny spatula
Oh, what a thrill.
Besmocked and bedecked out
In Pharmacist clothes
Knowing all of the things
That a Pharmacist Knows.
You're quick and efficient,
You're sharp and inventive,
It also just happens
You're anal rententive.
You read slips of paper
To get the specifics
From doctors who scribble out
Strange hieroglyphics.
Could it be Celebrex?
Or maybe Celexa
It might be a Z-Pak
Then it might be Zyprexa.
And you bill by computer
AWP
Minus 15 percent
Plus a buck twenty-three.
You fill and you bill
And you feel so dejected
'Cause half of your claims
Are being rejected.
So you pick up the phone
While computerized voices
Keep you waiting forever
Explaining the choices.
"Press 1 for directions,
Or maybe it's 2,
Push 'pound' for a message
It sucks to be you."
Then you pour at the pills
On your pill counting tray
And you count, and you count,
And you count pills all day.
And the customers gripe
And complain when you're fillin'
Could it be the whole world
Is on "Grouchacillin?"
"My pills are too big
And my co-pay's too high!
Take it four times a day?
I cannot comply!"
Then you scarf down your sandwich
In one single bite
Which if done in a restaurant
Would be impolite.
But a Doc's on line one
Mrs. Jones on line two
She has 500 pills
Will you cut them in two?
And the drug reps, they tap
On your counter, tap, tap,
To give you their spiel
Plus a load of free crap!
There's pens and there's post-its
There's free stuff galore
But the really cool clock's
For the doc who's next door.
Then ol' Mrs. Snifflemore
Gives you that smile
Any you know once again
That it's all been worthwhile.
So you hang up your smock,
And put down your free pen,
Tomorrow you'll do it
All over again.
Oh the things you will fill
For the folks who are ill.
With your bright shiny spatula
Oh, what a thrill.
Monday, September 08, 2003
It's funny how the very things that make you love your job, are the exact same things that make you hate your job. Crazy patients, I love you but.... PLEASE don't include me in your delusions. I don't want to know about your "invention submissions" to Sony or ATT&T. I don't want to hear about your past, half of which never happened. I'm NOT your therapist. I'm NOT your friend. I respect you as a person, and care aboout your well being, but beyond our professional relationship I don't want to know you.
