Treatment Refractory Psychosis:
This presentation is the property of its rightful owner.
Sponsored Links
1 / 26

Treatment Refractory Psychosis: What ’ s new and what ’ s not… PowerPoint PPT Presentation


  • 67 Views
  • Uploaded on
  • Presentation posted in: General

Treatment Refractory Psychosis: What ’ s new and what ’ s not… Dr Fiona Gaughran, Lead Consultant, National Psychosis Service, South London and Maudsley Trust. F Gaughran: Declaration of Interests. Last 3 years: Honoraria /Advisor: BMS, Roche . Family professional links; GSK, Lilly

Download Presentation

Treatment Refractory Psychosis: What ’ s new and what ’ s not…

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Declaration of interests honoraria

Treatment Refractory Psychosis:

What’s new and what’s not…

Dr Fiona Gaughran, Lead Consultant, National Psychosis Service, South London and Maudsley Trust

Declaration of Interests:

Honoraria/Grants/Advisor: BMS, Roche.

Family professional links; GSK, Lilly


F gaughran declaration of interests

F Gaughran: Declaration of Interests

Last 3 years:

Honoraria/Advisor: BMS, Roche.

Family professional links; GSK, Lilly

Previously funds for conferences / unrestricted research grants / advisory bodies:

Astra-Zeneca, Janssen, BMS, Lilly


National psychosis service

National Psychosis Service


National psychosis service why are people referred

National Psychosis Service: Why are people referred?


Declaration of interests honoraria

Team


Van os and kapur 2010

Van Os and Kapur, 2010

Assessment


Assessment of p ast treatments

Assessment of Past Treatments


Psychological therapies

Psychological Therapies


Declaration of interests honoraria

Kane J, Honigfeld G, Singer J et al. Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine. Arch Gen Psychiatry. 1988; 45: 789-796


Catie 2e

Quetiapine

Clozapine

Risperidone

Olanzapine

Any Cause

Lack of Efficacy

CATIE – 2E

1.0

0.8

0.6

0.4

0.2

0.0

Proportion of Patients Continuing Treatment

Patient’s Decision

Intolerability

1.0

0.8

0.6

0.4

0.2

0.0

0

3

6

9

12

15

18

0

3

6

9

12

15

18

Time to Phase 2 discontinuation (months)

McEvoy, et al. Am J Psychiatry 2006;163:600-610


Other evidence echoes this

Other evidence echoes this

  • Early rather than late (CATIE)

    • Offer it after only 1 AP?

  • Cost effectiveness – (Cutlass)

  • Clozapine given to 33% in NZ;

    • Low discontinuation.

    • Longer treatment associated with

      • Independent living,

      • more OT,

      • less compulsory Rx

      • less hospitalisation

        • Wheeler et al 2008


Clozapine optimisation

Clozapine Optimisation


Optimising clozapine essential including psychosocial aspect

Optimising clozapine essential, including psychosocial aspect


Re challenge after neutropaenia

Re-Challenge after neutropaenia

Was it all down to the Clozapine?

  • Do you challenge the CNRD?

  • Benign Ethnic Neutropaenia/ other meds at fault?

  • Does Lithium help?

  • When is GCSF useful and how is it best used?


Other problems

Other Problems

  • Post Cardiac Side effects

  • Post-pericarditis

  • Post-hepatitis

  • Close collaboration with Medical Specialists (with an interest in psychotropic side effects) is essential


Augmenting clozapine with another anti psychotic

Waddington et al, 1998

Barbui et al, 2009;

Attard and Gaughran, 2009

Zink et al 2010;

Augmenting clozapine with another anti-psychotic

  • “Marginal therapeutic benefit – but effect size small - Taylor & Smith 2009

  • “Modest therapeutic benefit – but effect size small” – Taylor et al 2012

  • increases mortality risk

    • High dose guidelines

    • Interactions can result in higher blood levels and longer QTc

    • Sulpiride

    • Amisulpride

    • Risperidone

  • Aripiprazole 5-15mg - Lower Clozapine dose / fewer s/e.


Augmenting clozapine with non ap

Augmenting Clozapine with non AP

  • Lamotrigine (Cochrane & Tiihonen et al 2005)

    • Meta-analysis shows effect

    • Also useful in bipolar depression and seizure prophylaxis

  • Topiramate (Kane 2011)

    • help or hinder? Weight???

  • Fish Oils – modest

  • Antidepressant for –ve symptoms (Cochrane)


Declaration of interests honoraria

Taylor et al, 2009, Leucht et al 2007, Schwarz et al 2008


Alternatives to clozapine

Alternatives to Clozapine

  • High Dose Olanzapine

    • Equivalent effect on psychopathology, but Clozapine better on GAF

    • Weight gain worse on Olanzapine

  • Combinations of anti-psychotics

    • NICE: “Do not initiate regular combined antipsychotic medication”

  • More work needed

  • FGA plus Mirtazepine

  • ECT plus anti-psychotics?

  • Melperone

  • Meltzer at el, 2008; Correll et al, 2008; Matheson et al, 2010; Tharyan et al, 2005


    Many novel treatments eg

    Many novel treatments, eg;

    • Anti-inflammatories;

      • Minocycline, ?aspirin!

    • Hormone Receptor Modulators

      • Tamoxifen; Oestradiol, etc

    • Memantine/ Donepezil/ Rivastigmine

    • Allopurinol

    • But none reliably useful


    Why do rcts promise so much and deliver so little

    Why do RCTs promise so much and deliver so little?

    • Inclusion of treatment-intolerant patients

    • Compared to un-optimised clozapine

    • Impossibility of blind trials with clozapine

    • Placebo effect

    • Interest of sponsor


    Summary

    Summary

    • Full MDT assessment

    • Optimise clozapine wherever possible

    • Manage adverse effects proactively

    • Augment in partial responders

    • Collaboration with medical specialties if rechallenge

    • Limited data for alternatives; consider high dose olanzapine, antipsychotic combinations, ECT? ….

    • All combined with psychological therapies (CBT, CRT, Family work) and OT


  • Login