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Aripiprazole is a dopamine partial agonist with a low risk of movement disorder and metabolic adverse effects.
We identified 228 patients consecutively prescribed aripiprazole in our unit and established outcome (continuation with treatment) six months after initiation.
The study cohort consisted of subjects of mean age 36.2 years (17-86) of whom 53.1% were male. Two thirds had a diagnosis of schizophrenia. Overall, 112 (49%) patients completed 6 months' treatment. Reasons for discontinuation were adverse events (n = 61, 53% of those who stopped), lack of effectiveness (n = 45, 39%) and a variety of unconnected reasons (n = 10, 9%). The majority of discontinuations (n = 76, 66%) occurred in the first 60 days of treatment, largely because of adverse effects. Most common adverse events reported were anxiety/agitation (n = 57, 25% of total cohort), insomnia (n = 43, 19%) and movement disorder (n = 24, 11%).
Treatment discontinuation was more likely for in-patients than out-patients (61% vs 42%, p = 0.005) and in those previously prescribed clozapine (p = 0.01). Modal initiation dose was 15mg for patients starting in the first year of the study and 10mg for those starting later. Initiation dose was not associated with outcome.
Aripiprazole showed a degree of effectiveness similar to that shown by other antipsychotics. Early-appearing, trivial adverse events are a major factor in treatment discontinuation. Outcome is best in out-patients and those not formerly treated with clozapine.
Clinical trial outcomes are heavily influenced by the non-naturalistic clinical trial process. Observations of outcomes in clinical practice are a valuable adjunct to clinical trial results.
Our null hypothesis was that clinically indicated switching to paliperidone palmitate had no effect on hospital admissions or hospital bed days.
This was a part-prospective mirror image study examining outcomes 2 years before starting paliperidone palmitate and 2 years after. Sensitivity analyses examined the effect of different placings of the mirror in the mirror image design.
We prospectively followed-up 225 patients prescribed paliperidone palmitate in clinical practice. At 2 years, 41.8% of patients were still receiving paliperidone palmitate. In the primary analysis, the mean number of admissions fell from 1.80 in the two years before starting paliperidone palmitate to 0.81 in two years following the drug’s initiation (outpatients) or two years following hospital discharge (inpatients) (P < 0.001). More than half of patients were not admitted to hospital during two years follow-up. Mean total bed days was reduced from 79.6 in the two years before to 46.2 in the two years after paliperidone palmitate initiation or discharge (P < 0.001). Sensitivity analyses gave broadly similar outcomes. Continuers demonstrated better outcomes than discontinuers in sensitivity analyses but not in the primary analysis.
Paliperidone palmitate initiation is associated with a substantial reduction in hospital admissions and days spent in hospital. The reduction in costs associated with reduced use of health care facilities is likely to exceed the purchase and administration costs of the drug.
To evaluate the prescribing of valproate in clozapine-treated individuals who may be at risk of seizure. We collected point-prevalent clinical characteristics and demographics of all in-patients prescribed clozapine in an acute mental health trust. Data were collected from case notes, electronic records and drug charts, and analysed against a set audit standard.
Data were collected for 81 in-patients. Of all deemed to be at risk of seizure (n=37) only 24% were prescribed valproate at a therapeutic plasma level.
The majority of patients prescribed clozapine at risk of seizures were not adequately protected from this risk. Clear guidelines are required.
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