High dose antipsychotic therapy as well as poly pharmacy are common practices despite lack of evidence to support such uses. Royal college of Psychiatrists (UK) recommended that high dose should be used only after other evidence based strategies have failed.Regular use of combinations of antipsychotics are discouraged by NICE (UK).
Can quality improvement programs change the prescribing behaviours?
Shubhra Mace and David Taylor from SLAM ( Maudsley) report the results of their 6 year long quality improvement program. Baseline data on high dose and multiple antipsychotic use was collected in 2006. The first quality improvement step was to issue guidance on prn ( as required ) use of antipsychotics. PRN was to be avoided , and if at all prescribed, needed to be reviewed every week.PRN prescription needed to be more detailed as well.This was disseminated across the hospital. Since 2007, high dose and combination uses were monitored by pharmacy. Prescribers needed to record rationale and do the necessary additional monitoring . During the next few years, these guidances and tailored exercises were repeated. Regular prescription reviews and discussions were implemented. Final survey was in 2012.
High dose prescribing decreased from 58% to 10%. polypharmacy decreased from 57% to 16%. These are impressive achievements. The national percentage of high dose prescription is 28%. National percentage of combination therapy is 38%.
The high dose calculation include 24 hr PRN prescription as well. PRN prescribed may not be given to patients. PRN use accounted for majority of the polypharmacy. Prn use is common place. Patients might be on only one regular antipsychotic, but would be written up for another antipsychotic for PRN use. clinicians in acute inpatient units would argue that the as needed prescription is very useful in controlling disturbed behaviour. However, the re audit at SLAM show that prescribers are less using as required antipsychotics for such purposes after the intervention.
There is some evidence to support combination antipsychotic use. The program set the target rate of prescribing high doses and combinations of antipsychotics on individual units to be below 20% .
Why 20%? : If 60% of all those with psychosis are treatment resistant (then they should be tried on clozapine) and 30% of them ( i.e. on clozapine) are not responding to clozapine alone adequately, there will be 18% requiring addition of second antipsychotic to clozapine.
Authors highlight the issue of initial resistance from prescribers to proposed changes. Support from top of the organisation was crucial.Persistence with quality targets was important.Benchmarkung and peer review were useful approaches to encourage prescribers to adopt the changes.
Comments: High dose monitoring form as recommended by Royal College is in widespread use in UK. Clinicians are more aware and patients are perhaps more vigilant of adverse effects of antipsychotics, particularly of higher dose/combinations. Changes in PRN use policy would further help to reduce polypharmacy.
Summary of the article:
Mace S, Taylor D. Ther Adv Psychopharmacol. 2015 Feb;5(1):4-12