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Archive for the month “December, 2013”

APA Aims to Nix ‘Knee-Jerk’ Antipsychotic Prescribing

A list of 5 key antipsychotic prescribing recommendations released by the American Psychiatric Association (APA) addresses some of the most common diversions from what should be standard practice, most of which can be attributed to one common culprit — the knee-jerk reaction to go directly to an antipsychotic before considering other alternatives.

Released last week and reported by Medscape Medical News at that time, the APA list is part of the Choosing Wisely effort, an initiative of the American Board of Internal Medicine Foundation that was designed to spur discussion on appropriate care regarding procedures and tests that are known to be overused or inappropriate. The initiative includes more than 80 medical specialty societies.

Released last week and reported by Medscape Medical News at that time, the APA list is part of the Choosing Wisely effort, an initiative of the American Board of Internal Medicine Foundation that was designed to spur discussion on appropriate care regarding procedures and tests that are known to be overused or inappropriate. The initiative includes more than 80 medical specialty societies.

 APA’s list of 5 key recommendations relating to antipsychotic prescribing

Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring

Patients on these drugs need to be monitored for the known metabolic adverse effects, and that can include taking a lipid profile and monitoring their weight, in addition to monitoring for potentially serious neurological side effects, such as tardive dyskinesia and extrapyramidal symptoms.

Don’t routinely prescribe 2 or more antipsychotic medications concurrently

There will always be circumstances when psychiatrists will want to prescribe 2 different medications, perhaps in an effort to work with different target profiles, for instance, but the admonition is that you shouldn’t start out prescribing 2 antipsychotic medications before you are able to see the effects of 1.

Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia

Clinicians will too often turn to antipsychotic drugs as a first-line treatment for dementia when other behavioral measures should be first considered.

Initial measures that should instead be considered in managing dementia include behavioral interventions, such as training family members on how to work with patients with techniques such as lighting orientation, kindness, music, or enlisting the help of skilled caregivers — these are all measures that can help patients with dementia settle down.

Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults

Antipsychotics are far down on the list of medications that should be used for insomnia, yet there are some prescribers using quetiapine (Seroquel [AstraZeneca Pharmaceuticals LP]), for instance, as a first line for sleep. Instead, begin with measures such as sleep hygiene, which can include measures ranging from avoiding stimulants or napping to making sure the bedroom is dark and the bed is comfortable.

Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders

It has become a first reaction in trying to get on top of a child’s or adolescent’s behavioral problem quickly, but the bottom line is that antipsychotic drugs are not to be used simply for a child who has frequent temper tantrums. Too many practitioners prescribe these drugs as a first option instead of trying to understand what they’re dealing with and making a more accurate diagnosis.

Think Before Prescribing

Philip R. Muskin, MD, a professor of psychiatry at Columbia University Medical Center in New York City, commented that a comprehensive list of routine antipsychotic prescribing habits that should be discouraged could feasibly be much longer, but he said the list captures key prescribing issues.

He noted that with dementia in particular, antipsychotics have become much more of a “go-to” drug than they should be.

“It’s not bad to put a patient on an antipsychotic for dementia, but it shouldn’t be the first thing you do because there’s really no evidence that antipsychotics treat dementia,” Dr. Muskin said.

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