Adherence to treatment guidelines in clinical practice: study of antipsychotic treatment prior to clozapine initiation

Howes, Oliver; Vergunst, Francis; Gee, Siobhan; McGuire, Philip; Kapur, Shitij; Taylor, David

doi:10.1192/bjp.bp.111.105833

Cited by 295 publications

(289 citation statements)

References 25 publications

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“…In certain cases of non-response to clozapine, the use of other second-generation antipsychotics, augmentation strategies with antidepressants and/or mood stabilizers, combination of antipsychotics and electroconvulsive therapy have been suggested as treatment alternatives, however, with limited evidence for their efficacy [2,[21][22][23]. Despite this, it was reported that clinicians do often try other approaches before clozapine prescription and there could be long delays before prescription of clozapine [24,25].…”

Section: Discussionmentioning

confidence: 98%

Prescribing trends in treatment-resistant schizophrenia

Görmez

Kurtulmuş

Can

2017

Psychiatry and Clinical Psychopharmacology

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Objectives: Schizophrenia is a common mental health condition associated with significant morbidity and excess early mortality. Treatment-resistant schizophrenia (TRS) occurs in about one in three patients diagnosed with schizophrenia. The aim of this study was to identify attitudes of a nationally representative sample of psychiatrists towards pharmacotherapy of patients with TRS, the potential factors related to their choice of various regimens, and to investigate the clinical outcomes of different methods employed. Methods: Psychiatrists were contacted through national e-groups and various psychiatry conventions. They provided information about their professional and demographic characteristics. They were asked to describe clinical and demographic characteristics of an adult patient with TRS under their care for at least 3 months. They reported on the medication change they made and the effect of this intervention on the positive symptoms and functioning of the patient. Results: Among the 207 patients reported on, only 28.7% were on monotherapy for TRS immediately before the change in medication. With the change made in treatment regime, 40.1% were switched to a different antipsychotic agent as monotherapy, 40.6% received combination therapy with two or more antipsychotic agents, 1.4% received high-dose antipsychotics, and 4.8% had augmentation with antidepressants or mood stabilizers. 13.1% psychiatrists employed more than one method. Of the whole sample, 48.3% were put on clozapine either as monotherapy or with other medications. The monotherapy and combination groups were compared in terms of characteristics of patients and prescribers, which revealed no significant difference (p > .05). There was also no difference found on the outcome variables of two groups (p > .05). Conclusions: Although polypharmacy was found to be a common practice, there seemed to be a comparably good ratio of clozapine utilization and of attempts of switching to monotherapy among the prescribers. There were no significant patient-or prescriber-related factors in relation to preference of treatment regimens, which need further investigation on larger samples. ARTICLE HISTORY

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Section: Discussionmentioning

confidence: 98%

Prescribing trends in treatment-resistant schizophrenia

Görmez

Kurtulmuş

Can

2017

Psychiatry and Clinical Psychopharmacology

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“…No que se refere à terapêutica, os pacientes com ER, por não responderem a doses usuais das drogas antipsicóticas de primeira e de segunda geração, são geralmente tratados tanto com doses mais altas de medicação do que as habitualmente utilizadas como com polifarmácia 4 , o que pode explicar a significância estatística quanto ao número de antipsicóticos utilizados nesses pacientes 14,15 , em concordância, portanto, com os dados encontrados no presente estudo. Além disso, os pacientes não refratários utilizaram maior número de associações com antidepressivos e benzodiazepínicos, o que possivelmente pode ter ocorrido por causa da maior possibilidade do diagnóstico de comorbidades psiquiátricas em pacientes com esquizofrenia quando há controle adequado dos sintomas psicóticos 16 .…”

Section: Discussionunclassified

Perfil clínico e sociodemográfico de pacientes com esquizofrenia refratária tratados em um centro terciário

Cezaretto

Silva

Ambrizzi

et al. 2014

J. bras. psiquiatr.

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Objetivos A esquizofrenia está associada a alto grau de incapacidade e importantes déficits neuropsicológicos, sociais e vocacionais. Pesquisas têm sido realizadas com o objetivo de identificar fatores preditivos para refratariedade, a fim de melhorar o tratamento e a qualidade de vida do paciente com esquizofrenia. O presente estudo teve o objetivo de verificar a frequência de pacientes com esquizofrenia refratária acompanhados em serviço terciário, estabelecer o perfil clínico e sociodemográfico e analisar possíveis fatores associados à refratariedade clínica. Métodos Sessenta e oito pacientes com esquizofrenia foram incluídos no estudo, sendo 36 refratários ao tratamento (52,9%). Os dados clínicos e sociodemográficos de ambos os grupos foram coletados, analisados e comparados. Um modelo de regressão logística foi elaborado com o objetivo de analisar possíveis fatores associados à refratariedade clínica. Resultados Entre o grupo refratário, houve maior frequência do sexo masculino (p = 0,03), número de antipsicóticos em uso (p < 0,01), internações ao longo da vida (p < 0,01) e de polifarmácia (p < 0,01). Escolaridade, estado civil, história familiar de esquizofrenia e uso de substâncias não foram confirmados como associados à refratariedade. Observou-se atraso temporal entre o estabelecimento da refratariedade clínica e a introdução da clozapina, indicado como o melhor antipsicótico para o tratamento de esquizofrenia refratária. Conclusão É importante e necessário o desenvolvimento de mais pesquisas a fim de investigar possíveis fatores clínicos e sociodemográficos preditores de refratariedade em pacientes com esquizofrenia, objetivando o início mais precoce de ações terapêuticas.

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“…During phase 3 of the CATIE study, 51% of patients had previously discontinued medications due to ineffective therapeutic response, but only 11% of patients were offered clozapine during phase 3. Studies of clozapine utilization have shown that adherence to guidelines has been poor through the years with clozapine been consistently underutilized in the US, UK, Canada, New Zealand and Australia [9,[21][22][23][24][25][26][42][43][44][45][46]. In a study of the Veterans Health Administration, only 2% of patients affected by schizophrenia were receiving clozapine [22].…”

Section: Clozapine Prescribing Trendsmentioning

confidence: 99%

“…However, none of the newer SGAs could demonstrate superiority to clozapine and in the last decade many published clinical practice guidelines [13][14][15][16][17][18][19][20] have recommended that clozapine be prescribed to patients with treatment-resistant schizophrenia, which has been defined as not responsive to two trials of any other antipsychotic medication (either FGA or SGA). Despite such recommendations and the overwhelming evidence of clozapine effectiveness, prescribing of clozapine appears to be low, delayed and often preceded by attempts at polypharmacy treatment, which lacks clinical evidence of effectiveness [21][22][23][24][25][26].…”

Section: Introductionmentioning

confidence: 99%

A Case of Drug-Induced Acute Dyskinesia Treated with Korean Medicine

Lee¹,

Shin²,

Kim³

et al. 2017

J Int Korean Med

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Background: Clozapine effectiveness in the treatment of refractory schizophrenia has been sustained by published evidence in the last two decades, despite the introduction of safer options. Discussion: Current clinical practice guidelines have strongly recommended the use of clozapine in treatment-resistant schizophrenia, but prescribing trends do not appear to have followed such recommendations. Clozapine is still underutilized especially in patients at risk of suicide. It seems that physicians are hesitant in prescribing clozapine due to concerns about serious adverse effects. Recent reports have highlighted the need to inform health professionals about the benefits of treating patients with clozapine and have voiced concerns about the underutilization of clozapine especially in patients at risk of suicide. Summary: Guidelines and prescribing patterns reported in various countries worldwide are discussed. Suggestions on how to optimize clozapine utilization have been published but more efforts are needed to properly inform and support prescribers' practices.

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Adherence to treatment guidelines in clinical practice: study of antipsychotic treatment prior to clozapine initiation

Abstract: Substantial delays to clozapine initiation remain and antipsychotic polypharmacy and high doses are commonly used prior to clozapine, despite treatment guidelines.

Cited by 295 publications

References 25 publications

Prescribing trends in treatment-resistant schizophrenia

Prescribing trends in treatment-resistant schizophrenia

Perfil clínico e sociodemográfico de pacientes com esquizofrenia refratária tratados em um centro terciário

A Case of Drug-Induced Acute Dyskinesia Treated with Korean Medicine

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