Antipsychotic polypharmacy – confusion reigns

Abstract

SummaryPolypharmacy is usually employed where single drugs are considered insufficiently effective. Some polypharmacy is rational and evidence based, some neither. Antipsychotic polypharmacy remains stubbornly widespread despite condemnation of the practice by numerous bodies. The practice could not be said to be evidence based. Its persistence probably stems from a well-meaning desire to improve response and from confusion about the mechanism of action of antipsychotics. In particular, the concept that more antipsychotic(s) must always be, or might be, ‘better’ is virtually groundless. Nonetheless, some specific antipsychotic polypharmacy regimens have shown particular benefits on adverse effect profiles. Targeted, evidence-based polypharmacy may be the way forward.

Increased use of antipsychotic long-acting injections with community treatment orders

“…In turn this allows patients a better chance of establishing some control over their illness and, with it, a measure of improved insight [Lambert et al 2009]. This study also found that high-dose (>100%BNF) antipsychotic prescribing and polyantipsychotic use is evident for patients on CTOs, although to a lesser extent than that reported for other UK samples [Tungaraza et al 2010;Paton et al 2008], despite guidelines to the contrary [Langan and Shajahan, 2010;Taylor, 2010a; National Institute for Clinical Excellence, 2009]. Compelling any patient to have potentially dangerous or even fatal high doses of medication is extremely problematic.…”

Clozapine antipsychotic polypharmacy: audit of use and patient monitoring

“…12 The evidence base for the necessity and utility of monitoring is weak. However, psychiatrists need to bear in mind that their practices may result in high-dose prescriptions, which current guidelines state require monitoring.…”

“…11 In an editorial which stimulated debate about additional antipsychotic prescribing in general, [12][13][14] Taylor stated that additional antipsychotic usage with clozapine is unlikely to be of value other than in the cases of cross-tapering when switching, rapid tranquillisation or specifically with the addition of aripiprazole. High-dose regimens, causing increased rates of dose-related adverse events including QT elongation, 15 can result from clozapine when used alongside other antipsychotics.…”

“…High-dose regimens, causing increased rates of dose-related adverse events including QT elongation, 15 can result from clozapine when used alongside other antipsychotics. Taylor 12 concludes with the hope that the audit procedures recommended by the National Institute for Health and Care Excellence (NICE) will be instrumental in reducing the extent of antipsychotic polypharmacy in psychiatric units in the UK.…”

Polypharmacy: should we or shouldn't we?

“…There is significant evidence that they reduce bed use, are cost-effective and patients prefer them to admission. 1 A CRHT team is dependent on the expertise and imagination of its staff to help understand and resolve a crisis. However, the risk to staff of working intensively with people who would otherwise be in hospital is not well documented.…”