New antipsychotic drugs produce better outcomes
September 1, 1997
New antipsychotic drugs produce better outcomes
Drugs have fewer side effects and cut costs
A new class of atypical antipsychotic drugs produce fewer negative side effects, offer better control of symptoms, and reduce hospital admissions by 60% with associated cost savings of up to $16,000 annually for patients suffering from psychotic disorders such as schizophrenia.
Many case managers shy away from these drugs because of their expense, says Lorraine Larsen, RN, CSW, a case manager and outreach worker with Project Outreach in New York City, which provides care and follow-up for severely mentally ill homeless patients. "It’s quite clear that these drugs are expensive, but there are cost-benefit studies which show that due to decreases in relapse rates, these drugs save money over time." In addition, drug manufacturers offer assistance programs for patients who cannot afford the medications, she notes.
The three drugs approved in this new wave of atypical antipsychotic drugs include clozapine, risperidone, and olanzapine. Larsen conducted a survey of pharmacies in the New York City area and found the average monthly cost of these drugs was:
• $170 for risperidone;
• $400 for olanzapine;
• $432 for clozapine.
In terms of clinical outcomes, the atypical antipsychotics provide better control for a broader range of psychotic symptoms with fewer side effects than traditional antipsychotics such as thorazine, says Mary Ann Nihart, MA, RN, CS, a partner with Professional Growth Facilitators in San Francisco. "In the past, we have gotten improvement of some symptoms of psychosis, but not all. About 15% of psychotic patients fail to improve with conservative antipsychotics. We believe this is because these drugs are dopamine blockers but do not affect other enzymes that contribute to psychosis, such as serotonin."
In addition, traditional antipsychotics often cause further social withdrawal and severe movement disorders. "Restlessness occurs in as many as 90% of patients treated with traditional antipsychotics. These side effects are what cause patients to stop taking their medications and lead to relapse," Nihart says.
Predicting outcomes
"There are some ways you can predict which drug will work best for a psychotic patient," Nihart says. "For example, clozapine works well but requires weekly blood draws. You have to know that your patient will come in each week for lab work. Risperidone comes in liquid form for patients who have difficulty swallowing tablets."
Clozapine carries an increased risk of seizure disorders, Larsen says, adding that the drug cannot be used with certain antibiotics and common antihistamines because of drug interactions.
Risperidone and olanzapine are associated with fewer movement disorders than thorazine and are safe for treating behavior problems associated with medical conditions such as mental retardation, dementia, and the psychotic symptoms sometimes associated with mood disorders, Larsen notes.
"Some clinicians have decided to prescribe the atypical antipsychotics for all psychotic patients. My own experience cautions a more conservative approach," she says.
Patients who Larsen says are well-suited for atypical antipsychotics include those with:
• poor response to conservative antipsychotics;
• only partial response to conservative antipsychotics;
• high incidence of side effects with conservative antipsychotics;
• a high number of negative symptoms, such as emotional withdrawal and lack of spontaneity.
"Those patients who present with a poverty of speech and social isolation are good candidates for the atypicals," she says. However, she cautions case managers not to develop care plans that switch psychotic patients abruptly from one drug to another. "Symptom flare-ups are often associated with dosing strategies. It’s very important to continue the old medication while introducing the new medication."
In addition, Larsen recommends following the adage, "If it’s not broken, don’t fix it." "If your patient is doing well on a traditional antipsychotic, there’s no reason to even consider switching to one of the atypicals," she says. "It’s also important never to change medications during times of conflict or change in your patient’s life."
Larsen cautions case managers to allow patients to adjust to external stressors before making a medication change. Some common stressors which Larsen says often lead to increases in psychotic behavior include:
• starting a new job;
• moving to a new home;
• seeing a new provider.
When you are considering switching a psych-otic patient to one of the atypicals, Larsen says you should start at the lowest possible dose. "Ris-peridone and olanzapine have both been found to be more effective at lower doses than those originally recommended. This is especially true for elderly patients who often respond at very low doses of the drugs. We usually recommend start-ing with the lowest possible dose and working up until good control of symptoms is reached," says Larsen. "In the elderly, you can start with risperidone doses as low as 0.5 mg daily."
Risperidone and olanzapine produce fewer side effects than traditional antipsychotics, but they do produce side effects, Larsen notes. The good news is that many of these side effects can be treated palliatively rather than with other medications. "For example, these are once daily drugs. If the drug causes insomnia, switch administration from evening to morning. If the drug causes drowsiness, switch administration from morning to evening."
In fact, any medication change requires a period of increased monitoring. Issues Larsen says case managers should consider before any medication change include:
• How often will patient be monitored?
• Who will monitor patient?
• How will the observer communicate with the clinician about patient response to medication?
"These issues must be clarified in advance of the medication change so that symptom flare-ups can be addressed and doses adjusted, if necessary, " she says.
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