Important areas of concern such as managing side effects and deficiency in evidence-based use of clozapine were identified. These can be targeted in training and professional development programme.
Around 40-70% patients with treatment-resistant schizophrenia fail to respond to clozapine. Though combining antipsychotics is commonly practised with non-responders, there is little evidence for its use.We carried out a retrospective review of case notes of patients with treatment-resistant schizophrenia on clozapine-aripiprazole combination at our clozapine clinic. We report changes in psychotic symptoms, social function, weight, total cholesterol, serum glucose, HDL, CGI and GAF score pre- and post-aripiprazole augmentation. Clozapine-aripiprazole combination was associated with 22% reduction of clozapine dose. Eighteen out of 24 (75%) lost a mean weight of 5.05 kg. There was improvement in positive and negative symptoms, social functions, weight loss and a moderate increase in HDL. Our findings suggest that clozapine-aripiprazole is a safe and tolerable combination; however, control trials are needed to validate our findings.
Studies of drug treatments are more likely to report favourable outcomes when they are funded by the pharmaceutical industry. We compared drug trials reported in three major psychiatric journals to investigate these influences. Independent studies were more likely to report negative findings than industry-funded studies. However, the involvement of a drug company employee had a much greater effect on study outcome than financial sponsorship alone.
Orally taken tablets in different formulations continue to have a central role in the treatment of various psychiatric and medical conditions. In order to improve compliance, reduce the frequency of taking medications and minimize the peaks and troughs associated with certain immediate-release formulations, pharmaceutical companies have developed a number of novel methods of delivering oral solid dosage medications in the form of controlled-release (CR) formulations. Some CR formulations have been associated with pharmacobezoars and false-positive findings on certain physical investigations. Though CR drugs are commonly used in psychiatry, clinicians appear to have a limited understanding of how they are released for absorption once ingested. Some have insoluble parts that are excreted in faeces as 'ghost pills'. Due to lack of awareness of this phenomenon to both patients and the physicians, anxiety has ensued in some patients. Some clinicians have been puzzled or have been dismissive when faced with curious patients wanting to know more after they had observed tablet-like looking structures in faeces. We present two cases from our clinical setting and a few drawn from the World Wide Web to highlight the role of CR medications and their association with the ghost pill phenomenon. The mechanisms involved in drug release relevant to psychiatry medications are also briefly reviewed. The ghost pill phenomenon occurs with certain CR medications. This is a normal and expected outcome related to drug-release mechanisms of some of these products. It is inevitable that some patients will see what looks like tablets or capsules in faeces. Raising awareness of this phenomenon among clinicians would facilitate discussions and information sharing at the initial process of medication prescribing. Awareness among patients and carers would also help to allay anxiety.
The majority of patients were prescribed antipsychotics within the guidelines. EIS was associated with an overall low antipsychotic discontinuation. There was also a short waiting time before clozapine was initiated following patients being accepted into EIS.
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