a while ago, talking to a person who started work on our discipline, left the issue of depot neuroleptics (it's true that they have increasingly cool names, but is a neuroleptic neuroleptic and depot is a depot, what you call it). Our correspondent said that the use of deposit these drugs had the obvious advantage of ensuring compliance . Nice. But, as we break some illusions and because we know that kings are the parents, I said yes, which effectively ensures compliance, but only for two weeks. Then the performance will be as the patient wants.
The fact is that many times we use medications to deposit precisely because we believe in ensuring compliance. And, in our opinion, is something wholly correct in many cases where the patient prefers well, take less medication by oral or convenience of administration. But we think it should be taken into account the patient's opinion on an issue that concerns him so directly. And it appears that we understand that sometimes it is necessary to administer medication even against the patient's opinion, at the time of a flare that requires involuntary admission to control anxiety and psychotic phenomena that cause. But forcing a stable patient psychopathologically preferred oral medication to prick a depot (or vice versa), it seems, apart from subtle, somewhat fascist.
But despite saying that you can go the opposite, as Scientists have interests and we like things as proven possible, we feel uneasy at the fact of not knowing the different studies comparing depot medications. As always, if any of our dear readers know of such a study and would enable us, we would be very grateful. Because we would hope to have proven through good randomized double-blind study the benefits of risperidone injection ( risperdal consists ) versus zuclopenthixol depot ( Cisordinol / CLOPIXOL ) or fluphenazine decanoate ( Modecate ), for example. For (almost) everyone says it is better but, hobbies of the scientific method, we would like something a little more, how to say ... based on more than opinions and discussions with visitors. Because we would like to know exactly the advantages of risperdal consists and, incidentally, if these benefits are clinically relevant for the patient to justify the price difference.
Recalling a previous post , the price per patient per month of risperdal consists of 100 mg every two weeks is 800 euros, that of zuclopenthixol two vials every two days is 33 euros and Modecate that of two ampoules every fifteen days, 6 Euros. Not to be demagogic (well, just a little), but considering everything out of the box of common public money, we ask whether the patient would not prefer to be one of the two flights and pass some of the money saved your pension or payment of rehabilitation devices, supervised apartments and perhaps more useful things. Because if we can not pay for everything (and taking into account that money is not only infinite but is tending to acabársenos) would like to know how to prioritize a bit.
The case is not aware of studies that compare typical depot neuroleptic with atypical, so far is only the RISPERDAL CONSTA. But we have found an interesting study on the drug, published recently in the New England Journal of Medicine ( going, silly magazine, we can dispense with a dismissive gesture if we do not like what the article said. .. ). This was a randomized, double-blind study comparing a group of schizophrenic and schizoaffective patients treated with RISPERDAL CONSTA, another oral antipsychotic medication group of different types. Give us verbatim (and kindly translated) findings:
The long-acting injectable risperidone duration was not superior to oral therapy chosen by the psychiatrists in patients with schizophrenia and schizoaffective disorder, who had been hospitalized or near the hospital, and also associated with more adverse effects in terms of damage to the injection site and extrapyramidal effects.
Wonderful. So, it's more expensive (remember that oral risperidone to 12 mg / d worth 150 euros) is not superior in symptoms, quality of life or function, and last but not least, causes more extrapyramidal side effects (not to mention the lesions on the buttocks or, if we care about the patient's dignity in deltoides). Really great.
But at this point, let us pause. When we compare the prices of these antipsychotics, we chose these doses (12 mg / d of oral risperidone, 100 mg/14 days intramuscularly) because they are the maximum doses used in our environment. Or so we thought when we wrote that entry, because then we have learned that some fellow, no doubt with more ability to manage psychotropic drugs, come with some frequency at doses of 150 mg/14 days of RISPERDAL CONSTA ( Update price per patient per month: EUR 1200 which is not bad for people who earn less than 400 pension ). It is striking It seems that one is more scientific biologist and the greater the dose used, the greater the amount of antipsychotic drugs together increased the amount of other medications that also requires, in the same patient.
But we assaulted a small but terrible question: do we really know what the recommended maximum sheet?. Because it is true that a doctor can prescribe higher doses of these if you think, preferably based on studies that will be better for clinical outcome. But it is also true that, beyond these maximum doses, the drug's safety is lower and the possibility of side effects More frequent and severe there. Let's look at the technical, easily accessible on the Internet:
oral Risperdal : doses above 10 mg / day have not proved more effective than lower doses, and may increase the incidence extrapyramidal symptoms. Since it has not been evaluated for safety to higher doses of 16 mg / day, doses should not be used above this level. Sheet as of February 2009.
Risperdal has : For most patients the recommended dose is 25 mg every two weeks intramuscularly. Some patients may benefit from higher doses of 37.5 mg or 50 mg. [...] In clinical trials, there was no additional benefit at doses of 75 mg. Not recommended higher doses of 50 mg every two weeks. Factsheet updated in November 2009.
We were, excuse the technicality flipped.
Let
repetition:
Risperdal has : For most patients the recommended dose is 25 mg every two weeks intramuscularly. Some patients may benefit from higher doses of 37.5 mg or 50 mg. [...] In trials clinical, no additional benefit was observed at doses of 75 mg. not recommend higher doses of 50 mg every two weeks. Factsheet updated in November 2009.
And we wonder: Are all those patients who are at doses of 100 or 150 mg could not perhaps have been with 50 mg?.
And also: when a patient takes 100 mg of intramuscular and also 12 mg of oral risperidone how much you have in your body?
hope, as we said before, do not accuse us of scaremongering. All this information is readily accessible on the internet and we believe legitimate and almost necessary, ask the questions that we are doing to improve our clinical practice. As we believe a patient's right to know the information available about the drugs they prescribe.
Returning to the question of dose is also the easy way out and witty type studies is that they are Americans and they use very low doses because they have fewer receptors, ha, ha, ha ... Grace messing with the Americans is very handy, and we have practiced for years like this and other issues, but something we stop to ponder why in the Schizophrenic patients is stable together with 12.5 mg every two weeks of intramuscular risperidone and in this country south of the Pyrenees (natural border of Europe, as everyone knows) we use in most patients 100 mg. And we wonder how we can distinguish patients who would respond to 12.5 mg if you have already put 100 ...
Finally, questions the wind ... The truth is that there are more important, because soon, soon, soon ... ( drumroll) ... We will have between us xeplion ! (To be clear, INVEGA depot), the expiration of the patent consists of on the horizon already. And we say (well, we do not) it's great, superb, the final antipsychotic ... (Well, until its patent expires in turn) and, furthermore, that can be given once a month and that is the height of comfort for the patient (and it will preserve its dignity, because you prick shoulder, not ass, teach that a nurse's ass really is undignified and stigmatizing). And, as today we are inquisitive, we also want to know how much public money will cost the great advantage of monthly injection ...
And you'll see as the risperdal has, so now seems wonderful to all, begins to stop as prescribed xeplion out the brand new, without any studies that compare.
But it will, as always, for the sake of patient.
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