Transcript COGNITIVE MODEL OF EMOTIONAL DISTRESS

Overuse of Dosulepin-Prothiaden in S&M
Dr Nora Gribbin
Consultant Psychiatrist & Medical Psychotherapist,
MRCPsych.
Cognitive Behaviour Therapist
DipCBT(Oxf), Acc. Member BABCP.
GP meeting 22nd June 2011
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Medications Management;Trust+S&M
Audit of Dosulepin prescribing
Practice at variance with guidelines
What to do?
Handout guidance
Medication Management
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DTC =
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Chief Pharmacist, Medical Director, Chair + Deputy Chair + Borough reps.
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MHIPF =
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Drugs & Therapeutic Committee
Mental Health Interface Prescribing Forum
Trust Pharmacists and S&M Lead, Brigitte Van Der Zanden (practice support)
Consultant Psychiatrist representatives incl, Dr. Nora Gribbin from DTC
GP Dr. Paul Alford and Mark Robertson, joint commissioning
Trust Formulary – new drugs
Off label prescribing list
MHIPF shared care policy
Practice Support Pharmacy
1987 to 2011
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Tricyclics prescribed widely
Advent of SSRIs
Sutton South CMHT; pts on Dosulepin
2007 NICE
MRHA -Drug Safety Update Dec 2007; Vol 1
Issue 5: 7
2009 NICE
Carshalton CMHT; pts on Dosulepin
MRHA - Drug Safety Update Dec
2007; Vol 1 Issue 5: 7
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Dosulepin has a small margin of safety
between the (maximum) therapeutic dose
and potentially fatal doses. Use in new
patients should be avoided; where
necessary, only specialist-care prescribers
should start treatment for patients who have
not previously received dosulepin, and
prescribers should limit the amount issued
per prescription.
MRHA - Drug Safety Update Dec
2007; Vol 1 Issue 5: 7
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To reduce the risk of fatal overdose,
dosulepin has been available only in
child-resistant blister packs since
November 2007
Pack sizes have been reduced to 2
weeks and a months supply
S&M Dosulepin prescribed items
March 2010 – February 2011
Dosulepin prescribed items
March 2010 - February 2011
600
500
400
300
200
100
0
Individual practice results
NICE clinical guidelines 90 and 91
(update of 23) 2009
“When prescribing drugs other than SSRIs, take into account:
– the increased likelihood of the person stopping treatment because of
side effects, and the consequent need to increase the dose gradually,
with venlafaxine, duloxetine and TCAs
– the specific cautions, contraindications and monitoring requirements
for some drugs
– that non-reversible monoamine oxidase inhibitors (MAOIs, such as
phenelzine), combined antidepressants (see page 21) and lithium
augmentation of antidepressants (see pages 21–22)
should normally be prescribed only by specialist mental health
professionals
– that dosulepin should not be prescribed.”
Choosing an antidepressant – see page 18
Issue date: October 2009
NICE clinical guidelines 90 and 91
(update of 23) 2009
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“Switching and combining antidepressants
When reviewing treatment after an inadequate response to initial
pharmacological interventions:
– check adherence to, and side effects from, initial treatment
– increase the frequency of appointments
– be aware that using a single antidepressant is usually associated with a lower
side-effect burden
– consider reintroducing treatments that have been inadequately delivered or
adhered to, including increasing the dose or switching antidepressants.
When switching antidepressants, consider:
– initially, a different SSRI or a better tolerated newer-generation antidepressant
– subsequently, an antidepressant of a different class that may be less well
tolerated (such as venlafaxine, a TCA or an MAOI).
Do not switch to, or start, dosulepin”.
Page 21- Sequencing treatments after an inadequate response
Issue date: October 2009
NICE clinical guidelines 90 and 91
(update of 23) 2009
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That dosulepin should not be
prescribed.
Do not switch to, or start,
dosulepin.
Dosulepin prescribing in S&M, Total ADQ
per Star PU March 2010 - February 2011
What to do!
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Don’t start dosulepin
Identify who is on it
Long term or recent - why?
Do not stop abruptly
Be aware of discontinuation and
withdrawal symptoms
Can it be withdrawn?
Addressing Dosulepin
Prescribing
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Discuss with the patient
Do a Cost Benefit Analysis
Discontinuation / Continuing / Switching
Consider Promethiazine for night sedation
Reduce cautiously
Switching - reduce with cross tapering
Continuing - monitor
If Continuation Therapy is indicated for
Recurrent Depression & U can Switch
SWITCHING; cross taper with alternative Antidepressant; max script=2 weeks of 75mg dosulepin
switching to;
SSRIs
VLF
MZP
TCAs
From Dosulepin;
Halve the dose,
Cross taper
Cross taper
Cross taper using
Reducing over 4
add SSRI, then
starting with
starting with,
eg; lofepramine
weeks or longer.
slow reduction
lowest dose
lowest dose
Limit prescription
which may be
sufficient in the
elderly
Be aware of potential pharmokinetic and pharmacodynamic problem of combined Antidepressant
MRHA - Drug Safety Update Dec
2007; Vol 1 Issue 5: 7
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A limited number of tablets should be prescribed to reduce the
risk of overdose for all patients, especially those at risk of
suicide
A maximum prescription equivalent to 2 weeks’ supply of 75 mg
per day should be considered in patients with increased risk
factors for suicide at initiation of treatment, during any dose
adjustment, and until improvement occurs
Concomitant medicines that may increase the risk of toxicity
associated with dosulepin should be avoided
There is no immediate need to change treatment for
established patients
Patients should be advised to store tablets securely, out of sight
and reach of children
In cases of overdose, patients should seek immediate medical
attention
Examples of medicines to avoid
during dosulepin use. DSU Dec 07 vol 1 5.7
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alcohol; general anaesthetics; opioid
analgesics; anti-arrhythmics;
moxifloxacin; SSRIs; MAOIs; sedating
antihistamines; antipsychotics;
anxiolytics; hypnotics; atomoxetine;
diltiazem; verapamil; disulfiram;
dopaminergics; lithium; pentamidine
isethionate; sibutramine; and
sympathomimetics
If Continuation Therapy is indicated for
Recurrent Depression
Continuing with Dosulepin, guidance points;
Lowest dose
Interactions with concomitant medication
Max script = 2 weeks of 75mg per day
Suicide Risk monitoring; O/D is an Emergency
Limited number of tabs
Mental state monitoring
Out of reach of children
Cardiac monitoring
AVOID; alcohol; general anaesthetics; opioid analgesics; anti-arrhythmics; moxifloxacin; SSRIs; MAOIs; sedating
antihistamines; antipsychotics; anxiolytics; hypnotics; atomoxetine; diltiazem; verapamil; disulfiram;
dopaminergics; lithium; pentamidine isethionate; sibutramine; and sympathomimetics
DSU Dec 07 vol1 5:7
Handouts available
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Drug Safety Update Dec 2007; Vol 1
Issue 5: 7
Guidance; to address Dosulepin
Prescribing