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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 Medications Management;Trust+S&M Audit of Dosulepin prescribing Practice at variance with guidelines What to do? Handout guidance Medication Management DTC = Chief Pharmacist, Medical Director, Chair + Deputy Chair + Borough reps. MHIPF = 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 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 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 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 “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 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! 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 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 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 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 Drug Safety Update Dec 2007; Vol 1 Issue 5: 7 Guidance; to address Dosulepin Prescribing