Incidence and costs of polypharmacy: data from a randomized,double-blind,placebo-controlled study of risperidone and quetiapine in patients with schizophrenia or schizoaffective disorder

ABSTRACT

Objective: The use of adjunctive psychotropics and the costs of poly­pharmacy in patients randomized to receive risperidone or quetiapine were compared in a placebo-controlled double-blind study conducted in India, Romania, and the United States.

Methods: The efficacy and safety of risperidone, quetiapine, and placebo were compared in a 14-day monotherapy phase in patients experiencing an acute exacerbation of symptoms of schizophrenia or schizoaffective disorder. This was followed by a 28-day, additive-therapy phase during which addition of antipsychotics or other psychotropic medications was permitted. Risperidone was received by 153 patients in the monotherapy phase and 133 in the additive therapy phase, quetiapine by 156 and 122, respectively, and placebo by 73 and 53. Rates of polypharmacy were examined using the Cochran–Mantel–Haenszel, Kaplan–Meier, and Cox regression methods. Costs of poly­pharmacy were analyzed by non­parametric Wilcoxon 2-sample tests.

Results: Primary study results have been reported elsewhere (Potkin et al., Schizophr Res 2006;85:254-65). Mean (±SD) doses at the additive-therapy baseline were 4.7 ± 0.9?mg/day of risperidone and 579.0 ± 128.9?mg/day of quetiapine. Additional psychotropics were received by 36% of the risperidone group, 58% of the quetiapine group (?p < 0.01), and by 58% of the placebo group. Antipsychotics accounted for > 95% of the added psychotropics, the most common being olanzapine and haloperidol. The relative risk (quetiapine vs. risperidone) for antipsychotic polypharmacy was 1.90 (?p = 0.001; 95% CI 1.29, 2.80). The mean projected cost of additional antipsychotics per randomized patient during the additive-therapy phase was $57.03 in the risperidone group and $101.64 in the quetiapine group (?p < 0.01).

Conclusions: The results confirm earlier reports of higher rates of poly­pharmacy with quetiapine than with risperidone. The findings also reveal substantial between-treatment differences in costs associated with poly­pharmacy. Limitations of the study include that the study was of short duration and that a high proportion of patients were recruited from countries other than the United States.     

A critical review of atypical antipsychotic utilization: comparing monotherapy with polypharmacy and augmentation

The atypical antipsychotics risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole have become first-line treatment for schizophrenia because they reduce the positive symptoms of psychosis but do not have a high incidence of extrapyramidal symptoms. However, these agents, like other antipsychotics, may take as long as 16 or more weeks to produce a response, and even with prolonged treatment are unlikely to evoke responses greater than 50% improvement in symptoms. This has led to the experimental use of high atypical antipsychotic doses, antipsychotic polypharmacy, and augmentation with other psychotropic drugs, all of which occur commonly in clinical practice. This article reviews the current evidence for these increasingly common means of treating schizophrenia and psychosis, with particular emphasis on polypharmacy and augmentation. To date, there are only two controlled studies of antipsychotic polypharmacy involving an atypical antipsychotic; the rest of the data are uncontrolled trials and case reports that describe a mixture of positive and negative findings. One multicenter, double-blind trial shows a faster onset of action when divalproex is added to risperidone or olanzapine than with antipsychotic monotherapy. A small double-blind study demonstrates efficacy when lamotrigine is added to clozapine. The rest of the data on augmentation with anticonvulsants are uncontrolled, and most report adverse effects. With the exception of divalproex, there are currently no compelling data to justify the use of antipsychotic polypharmacy or augmentation. Existing evidence suggests that the best treatments for schizophrenia and psychosis may be long-term trials of a sequence of atypical antipsychotic monotherapies at therapeutic doses.     

Comparing the treatment patterns of patients with schizophrenia treated with olanzapine and quetiapine in the Pennsylvania Medicaid population

ABSTRACT

Objective: Compare treatment patterns for patients with schizophrenia treated with olanzapine versus quetiapine in the Pennsylvania Medicaid population.

Methods: Patients (18–64 years) with a diagnosis of schizophrenia (ICD-9-CM: 295.xx) and treated with olanzapine or quetiapine were identified from the Pennsylvania Medicaid claims database (1999–2003). Patients were continuously enrolled in the 12-month pre- and 12-month post-initiation periods. To control for selection bias, propensity score method with optimal matching algorithm was used to match patients from the two treatment groups. The key study outcomes including rates of augmentation, polypharmacy, discontinuation, and switching were analyzed using Kaplan-Meier survival analysis. Medication possession ratio and use of concurrent psychotropic drugs were also compared between the two groups.

Results: A total of 2321 quetiapine and 6929 olanzapine patients were identified. In all, 2321 pairs of patients were matched between the two groups and they had similar baseline characteristics. Over the 12-month study period, olanzapine patients had a better medication adherence (0.47 vs. 0.43; p?<?0.0001), and were less likely to use other psychotropic medications concomitantly (all p?<?0.05). Olanzapine patients had a significantly lower risk of augmentation and polypharmacy with other antipsychotics. The 6-month augmentation rates with antipsychotics were 12.9% and 16.7% for olanzapine and quetiapine, respectively (p?<?0.05); the polypharmacy rates with any antipsychotics were 12.5% and 18.6% for olanzapine and quetiapine, respectively (p?<?0.001). No significant differences were observed for discontinuation and switching between the two treatment groups. Sensitivity analysis with a 60-day minimum monotherapy requirement showed similar results.

Limitations: This study's limitations include the analysis of a single Medicaid state, which may limit the generalizability to the entire Medicaid population with schizophrenia or to all patients with schizophrenia.

Conclusion: This large Medicaid claims database analysis showed that olanzapine patients were significantly more compliant to treatment and less likely to augment or have polypharmacy with antipsychotics during the course of treatment compared to quetiapine patients.     

Tolerability of outpatient antipsychotic treatment: 36-month results from the European Schizophrenia Outpatient Health Outcomes (SOHO) study

SOHO is a 3-year, prospective, observational study of schizophrenia patients who started a new antipsychotic in 10 European countries. Cohorts of patients were defined according to the antipsychotic started at baseline: olanzapine, risperidone, quetiapine, amisulpride, clozapine, oral typical and depot typical antipsychotics. Tolerability in terms of rates of extrapyramidal symptoms (EPS), tardive dyskinesia (TD), anticholinergic use, loss of libido/impotence, amenorrhoea/galactorrhoea/gynaecomastia, and weight change was assessed in 4939 patients who started monotherapy. Logistic regression models related medication initiated at study entry to adverse events over follow-up, adjusting by baseline differences among treatment cohorts. Patients taking typical antipsychotics or risperidone were more likely to experience EPS and TD during follow-up than patients taking olanzapine. Patients taking olanzapine were less likely to have loss of libido/impotence during follow-up than patients in the risperidone, amisulpride, clozapine, oral typical and depot typical cohorts. Weight gain occurred in all groups, but was greater with olanzapine. In conclusion, antipsychotics have different tolerability profiles in terms of the adverse events we monitored. Results should be interpreted conservatively due to the observational study design.     

Three-year antipsychotic effectiveness in the outpatient care of schizophrenia: observational versus randomized studies results.

Antipsychotic discontinuation rates are a powerful indicator of medication effectiveness in schizophrenia. We examined antipsychotic discontinuation in the Schizophrenia Outpatient Health Outcomes (SOHO) study, a 3-year prospective, observational study in outpatients with schizophrenia in 10 European countries. Patients (n=7728) who started antipsychotic monotherapy were analyzed. Medication discontinuation for any cause ranged from 34% and 36% for clozapine and olanzapine, respectively, to 66% for quetiapine. Compared to olanzapine, the risk of treatment discontinuation before 36 months was significantly higher for quetiapine, risperidone, amisulpride, and typical antipsychotics (oral and depot), but similar for clozapine. Longer medication maintenance was associated with being socially active and having a longer time since first treatment contact for schizophrenia, whereas higher symptom severity, treatment with mood stabilizers, substance abuse, having hostile behaviour were associated with lower medication maintenance. Antipsychotic maintenance in SOHO was higher than the results of previous randomized studies.     

Medication patterns and costs associated with olanzapine and other atypical antipsychotics in the treatment of bipolar disorder

ABSTRACT

Objective: Atypical antipsychotics are playing an increasing role in the treatment of bipolar disorder. The objective of this study was to assess the medication treatment patterns and costs associated with different atypical antipsychotics.

Methods: PharMetrics Integrated Database for medical and pharmacy claims was used to assess medication patterns and healthcare costs associated with atypical antipsychotics in the treatment of bipolar disorder. Patients who initiated on olanzapine, risperidone, quetiapine or ziprasidone as monotherapy or in combination with other bipolar medications between 01/2003 and 01/2004 were followed for 1 year. Pair-wise group comparisons were made between olanzapine and other atypical antipsychotics using Wilcoxon without adjustment, log linear regression model with adjustment, and propensity score-adjusted bootstrapping methods.

Results: Among 1516 patients with bipolar disorder, olanzapine (n = 507, 51%) was significantly (?p < 0.01) more likely to be initiated as the mono-bipolar medication than risperidone (n = 424, 40%), quetiapine (n = 463, 36%) or ziprasidone (n = 122, 25%). Post-initiation, olanzapine was used as the mono-bipolar medication for significantly (?p < 0.01) more days (73.4) than risperidone (52.9), quetiapine (56.2) and ziprasidone (36.6). Annual healthcare costs incurred by patients with bipolar disorder varied from $14?216 for risperidone, $15?208 for olanzapine, $18?087 for quetiapine to $18?729 for ziprasidone treatments. No statistically significant differences in the annual healthcare costs were observed between olanzapine and risperidone treatments. Statistically significant differences between olanzapine and quetiapine were observed in two of the three models compared (?p < 0.01, Wilcoxon; p = 0.024, log linear; p = 0.390, propensity score-adjusted bootstrapping) and between olanzapine and ziprasidone in one of the three models (?p < 0.01, Wilcoxon; p = 0.068, log linear; p = 0.394, propensity score-adjusted bootstrapping).

Limitations: Those arising from the data source and nature of retrospective assessments. Potential bias may also exist due to the presence of confounding factors and unobserved conditions and characteristics. As such, results of this study need to be considered in the context of its limitations and generalizability should be reserved to similar patient populations.

Conclusions: Antipsychotic medication use patterns were statistically significantly different among atypical antipsychotics in the usual treatment of bipolar disorder. Olanzapine appears to be more likely used as a mono-bipolar medication compared with risperidone, quetiapine, and ziprasidone. The annual healthcare costs associated with the treatment of bipolar disorder by olanzapine and risperidone were similar, and the costs of these treatments were lower than with quetiapine or ziprasidone.     

The prevalence of antipsychotic polypharmacy in schizophrenic patients discharged from psychiatric units in Poland

BackgroundThe term antipsychotic polypharmacy (APP) refers to the concurrent use of two or more antipsychotic drugs in schizophrenia. The aim of this study was to investigate the range of APP in schizophrenic patients discharged from psychiatric units in Poland, and to determine its demographical and clinical correlates.MethodsData on the pharmacological treatment of 207 patients with a diagnosis of schizophrenia, discharged from six psychiatric hospitals from September–December 2011 were recorded by experienced psychiatrists. Clinical and demographical information was obtained on each patient. The severity of symptoms at admission, and their improvement during hospitalization were assessed using the Clinical Global Impression Scale.ResultsAt discharge, 52.7% of the patients were prescribed one, 42.5% two and 4.8% three antipsychotic drugs (AP). When two AP were applied, it was usually a combination of two second generation antipsychotics (SGA) (46%), or of both first generation antipsychotics (FGA) and SGA (48%). The SGA's olanzapine and risperidone were those most commonly prescribed. Patients treated with two or more AP had a higher number of previous hospitalizations than patients receiving antipsychotic monotherapy. Mood stabilizers were prescribed for nearly one third of the patients, while antidepressants and benzodiazepines were prescribed for fewer than 10%.ConclusionsThe prevalence of polypharmacy in Poland is similar to that reported in other countries. This may suggest that, in a substantial proportion of schizophrenic patients clinical response to the antipsychotic monotherapy is unsatisfactory. Further studies focusing on the efficacy and safety of strategies in the treatment of patients with schizophrenia not responding to antipsychotic monotherapy are necessary.     

Antipsychotic-induced type 2 diabetes: evidence from a large health plan database

Case evidence suggests that some of the atypical antipsychotics may induce type 2 diabetes. The objective of this study was to evaluate the association of antipsychotic treatment with type 2 diabetes in a large health plan database. Claims data for patients with psychosis within a health plan of nearly 2 million members were analyzed using logistic regression. Frequencies of newly treated type 2 diabetes in patients untreated with antipsychotics and among patients treated with quetiapine, risperidone, olanzapine, and conventional antipsychotics were compared. Based on exposure measured in months of antipsychotic treatment, quetiapine and risperidone patients had estimated odds of receiving treatment for type 2 diabetes that were lower than those of patients untreated with antipsychotics (not statistically significant); patients treated with conventional antipsychotics had estimated odds that were virtually equivalent to those of patients untreated with antipsychotics; olanzapine alone had odds that were significantly greater than those of patients untreated with antipsychotics (P = 0.0247). Odds ratios based on 8 months of screening for pre-existing type 2 diabetes and assuming 12 months of antipsychotic treatment were: risperidone = 0.660 (95% CI 0.311-1.408); olanzapine = 1.426 (95% CI 1.046-1.955); quetiapine = 0.976 (95% CI 0.422-2.271); and conventional antipsychotics = 1.049 (95% CI 0.688-1.613). Case reports, prospective trials, and other retrospective studies have increasingly implicated olanzapine and clozapine as causing or exacerbating type 2 diabetes. Few have implicated risperidone while evidence on quetiapine has been limited. This study supports earlier findings on risperidone versus olanzapine and builds evidence on quetiapine. Additional studies are needed to evaluate the association of antipsychotic treatment with type 2 diabetes.     

Switching from risperidone to olanzapine in a one-year,randomized, open-label effectiveness study of schizophrenia

ABSTRACT

Objective: Switching medications is common in the treatment of schizophrenia. This study examines the effectiveness of olanzapine therapy following a clinically warranted switch from risperidone during treatment of patients with schizophrenia.

Research design and methods: This post-hoc analysis used data from the risperidone arm of a randomized, open-label, 1-year study of patients with schizophrenia. Study protocol permitted antipsychotic switching when clinically warranted, and outcomes were assessed with standard psychiatric measures. Statistical analyses assessed changes from pre- to post-medication switch and endpoint comparisons between patients switched from risperidone to olanzapine and patients continued on risperidone.

Results: Most patients who switched from risperidone switched to olanzapine (43/60; 71.7%). Average duration of risperidone treatment prior to switching was 86 days (mean modal dose 4.0?mg/day). Most switchers (86%) completed the 1-year study on olanzapine (average duration 241 days; mean modal dose 12.0?mg/day). Following switch to olanzapine, patients experienced significant improvements on clinical (Brief Psychiatric Rating Scale) and social (Quality of Life Inventory) parameters, with similar proportions of patients achieving remission status at endpoint compared with risperidone patients not requiring medication switch (41.9 vs. 35.5%). Mean weight gain for switchers was approximately 0.4?kg while on risperidone (average treatment duration <?3 months) and 2.4?kg on olanzapine (average treatment duration approximately 8 months).

Conclusions: This study suggests that olanzapine is an effective treatment option for schizophrenia patients requiring a switch from risperidone. Given the small sample size and lack of a comparative group, one cannot determine if other medication options would have been as effective as the switch to olanzapine. Thus, further research is warranted.     

Off-label second generation antipsychotics for impulse regulation disorders: a review

Impulse regulation disorders and substance abuse disorders have considerable consequences for treatment and prognosis of comorbid psychiatric disorders. Second generation antipsychotics (SGA) are frequently prescribed off-label for these disorders. This off label use of SGA entails some systematic problems, such as lack of knowledge about their long-term efficacy and effects, including side-effects, and unclarity about doses in certain disorders and patient groups, for example children and adolescents. In this review we describe the evidence that supports off-label use of the second generation antipsychotics risperidone, olanzapine, clozapine, ziprasidone, quetiapine and aripiprazole in impulse regulation disorders and substance abuse disorders. We discuss these disorders together since we argue that the central feature of impulsivity in both disorders is a possible target for antipsychotic medication. Subsequently we discuss the adverse effects of these agents and we consider some hypotheses about the mechanism of action in these disorders. Several double-blind randomised placebo-controlled trials have proven that risperidone is effective in attention-deficit and disruptive behavior disorders in children and adolescents, in behavioral problems and subaverage intelligence and in tic disorders. Some double-blind randomised placebo-controlled trials, open-label studies and case reports find efficacy of olanzapine in tic disorders and pervasive developmental disorder. Risperidone and olanzapine are found to be ineffective in substance use disorders. In tic disorders two double-blind randomised placebo-controlled trials show inefficacy of clozapine and efficacy of ziprasidone. Some open-label studies found no benefit of quetiapine in pervasive developmental disorder. Single-blind and open-label studies argue the benefit of clozapine, quetiapine and aripiprazole in substance abuse and dependence. A few open-label studies and case reports suggest efficacy of quetiapine, aripiprazole and ziprasidone in attention-deficit and disruptive behavior disorders in children and adolescents and in tic disorders. Metabolic side effects such as hyperglycaemia and diabetes mellitus, weight gain and hyperlipidaemia are reported in all SGA, but especially in clozapine and olanzapine. In children they seem to be more pronounced than in adults. The most reported side effect in off-label SGA use in children, adolescents and adults is sedation. More double-blind randomised placebo-controlled trials into the long-term efficacy and safety of second generation antipsychotics are needed. Moreover head to head comparison of SGA against each other and against first-generation antipsychotic medication is still needed to determine the superiority of specific agents in treatment of specific disorders.     

Clozapine discrimination with a low training dose distinguishes atypical from typical antipsychotic drugs in rats

Rationale: Previous drug discrimination studies with clozapine have not reliably distinguished between atypical and typical antipsychotics. Objectives: The present study was conducted to determine whether low-dose clozapine drug discrimination could distinguish atypical from typical antipsychotics. Methods: Rats were trained to discriminate 1.25 mg/kg clozapine from vehicle in a two-lever drug discrimination procedure. Results: Generalization testing revealed full substitution with the atypical antipsychotics olanzapine (90.3% maximum generalization), sertindole (99.8%), and risperidone (87.1%) and partial substitution for quetiapine (seroquel, 66.4%) and the typical antipsychotics haloperidol (56.8%) and thioridazine (74.3%). Remoxipride (23.1%) and the typical antipsychotics chlorpromazine (27.9%) and fluphenazine (29.5%) did not reliably substitute for clozapine. Conclusions: In contrast to previous clozapine drug discrimination studies with higher training doses, the atypical antipsychotics olanzapine, sertindole, and risperidone reliably substituted for clozapine while typical antipsychotics did not. These results suggest that low-dose clozapine drug discrimination may be a more sensitive assay for distinguishing atypical from typical antipsychotic drugs. Received: 3 August 1999 / Final version: 9 December 1999     

Switching treatment-resistant patients with schizophrenia or schizoaffective disorder to olanzapine: a one-year open-label study with five-year follow-up

Objective: To determine whether patients with treatment-resistant schizophrenia or schizoaffective disorder would respond when switched to olanzapine and whether they could maintain their response on this atypical anti psychotic.

Research design and methods: In this single-center, observational, 1-year open-label study, a cohort of patients was switched to olanzapine due to failure on previous treatment. The patients were followed up (retrospectively) for an additional 5 years. Patients had schizophrenia or schizoaffective disorder and all but one were treatment-resistant. The starting dose was 10?mg/day, with dosage adjustments based on physician judgment.

Main outcome measures: The CGI-S and CGI-I scales were the primary outcome measures. During the observation period, positive and negative symptoms, hospital readmission rates and duration of hospitalization were measured, and treatment-emergent adverse events recorded.

Results: Mean age of patients (n?=?25) was 39.7 years; 19 were male, and all were Caucasian. The mean number of antipsychotics used prior to olanzapine was 4.6 with risperidone (76%) being the most common. The mean duration of olanzapine therapy was 8.6 months. The average number of hospital admissions per patient dropped from 1.32 during the year prior to olanzapine therapy to 0.39 after starting olanzapine. Total number of hospital days was 1042 the year before and 258 the year after olanzapine treatment. The mean CGI-S score improved from markedly ill at baseline to borderline/mildly ill at study end. The mean CGI-I score was rated much improved at study end. Few adverse events occurred during the study. Twelve patients remained on olanzapine monotherapy after 5 years of treatment (mean duration of 62 months).

Conclusions: Olanzapine may be a treatment option for patients who fail to respond to treatment with other antipsychotics. Importantly, this is one of the first reports showing that patients with schizophrenia can be maintained on atypical antipsychotic monotherapy for at least 5 years.     

Daytime sleepiness and EEG abnormalities in patients treated with second generation antipsychotic agents

BackgroundThe aim of this study was to verify whether or not an increased prevalence of excessive daytime sleepiness (EDS) or EEG abnormalities is observed in patients with schizophrenia spectrum disorders (SSD), and to compare the effects of second generation antipsychotics (SGA) on patients’ daytime sleepiness level and EEG recordings.MethodsEEG recordings and self-reports of EDS, assessed with Epworth (ESS) and Stanford (SSS) Sleepiness Scales, were compared between 244 patients with SSD and 82 patients with anxiety, personality or behavioral disorders (non-psychotic disorders, NPD). To examine the effects of various SGA, patients treated in monotherapy with aripiprazole, olanzapine, clozapine, risperidone and sertindole were compared.ResultsA higher prevalence of abnormal EEG recordings was observed in SSD patients. No significant differences in average daytime sleepiness were found between patients with SSD and NPD; however, patients with SSD had longer sleep duration. Aripiprazole treatment was associated with significantly smaller and less frequent EEG abnormalities than treatment with any other SGA, while treatment with clozapine and olanzapine was related to an increased prevalence of severe EEG abnormalities. Patients with SSD treated with SGA in monotherapy were less sleepy than unmedicated patients with NPD.ConclusionsAlthough antipsychotics may have profound effects on EEG patients with schizophrenia do not have higher daytime sleepiness than patients with anxiety/personality disorders. Patients with schizophrenia may compensate sedative effects of antipsychotic treatment with sleep duration prolongation and report even less sleepiness than non-psychotic patients.     

658例门诊精神病患者抗精神病药物应用分析

目的了解门诊精神病患者抗精神病药物的使用情况，为临床合理用药提供参考。方法抽样调查浙江省立同德医院2005年9月658张抗精神病药物处方用药情况。结果共涉及25种治疗方案，其中使用1种抗精神病药物的治疗方案有7种348张（52．89％），使用2种的有15种307张（46．66％），使用3种的有3种3张（0．45％）。抗精神病药物治疗方案居前5位的依次为利培酮、氯氮平、奥氮平、氯氮平＋碳酸锂、奎硫平；使用率居前5位的分别是氯氮平（35．41％）、利培酮（25．68％）、舒必利（19．76％）、奥氮平（13．83％）、奎硫平（13．37％）。结论该院抗精神病药物的处方用药情况基本合理，非典型抗精神病药物已成为临床首选。     

Effect on lipid profiles of switching from olanzapine to another secondgeneration antipsychotic agent in veterans with schizophrenia

ObjectiveTo compare (1) mean low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride differences after switching from olanzapine to quetiapine, risperidone, or ziprasidone and (2) the mean lipid change between switch patterns.DesignRetrospective, naturalistic, nonequivalent control group design.SettingUnited States between April 1, 2002, and September 30, 2002.Patients1,826 U.S. Veterans Healthcare System enrollees with diagnoses of schizophrenia or schizoaffective disorders and receiving a second-generation antipsychotic (SGA) medication.InterventionsAnalysis of data from the Veterans Information Systems and Technology Architecture.Main outcome measuresDifferences in LDL-C, HDL-C, and triglycerides and mean differences between switch patterns. Predictors were the type of switch (e.g., olanzapine to quetiapine) and switch patterns (e.g., olanzapine to quetiapine versus olanzapine to risperidone). Data were analyzed using Pearson’s χ2 and multivariate analysis of covariance with planned comparisons.ResultsAfter adjusting for age, gender, and race/ethnicity, LDL-C decreased significantly among patients switched from olanzapine to ziprasidone (–16.9 mg/dL, P <0.01) and olanzapine to quetiapine (–7.6 mg/dL, P = 0.04) and trended upward in patients switched from olanzapine to risperidone (+6.6 mg/dL, P = 0.12). Triglyceride levels decreased among those switched from olanzapine to ziprasidone (–62.9 mg/dL, P <0.01) and olanzapine to risperidone (–48.5 mg/dL, P <0.01) but not among veterans switched from olanzapine to quetiapine (+7.8 mg/dL, P = 0.54). HDL-C levels did not change significantly when veterans were switched from olanzapine to quetiapine, risperidone, or ziprasidone.ConclusionSwitching SGAs can increase or decrease cardiovascular risk depending on the clinician’s follow-on SGA choice. LDL-C and triglyceride levels decreased significantly among veterans switched from olanzapine to ziprasidone. Switching to quetiapine was associated with a reduction in LDL-C, while switching to risperidone resulted in lower triglyceride levels. Clinicians should use these results when building a patient care plan that includes switching of SGAs.     

Pharmacy cost evaluation of risperidone,olanzapine, and quetiapine for the treatment of schizophrenia in acute care inpatient settings

SUMMARY

Objective: This study examines total pharmacy cost and usage patterns of schizophrenic patients in acute mental health inpatient settings for three atypical antipsychotics – risperidone, olanzapine, and quetiapine. Despite the readily available unit cost information for drugs, actual pharmacy costs may deviate significantly from ‘labeled costs’. Recent research findings indicate the need for more robust evaluation of such pharmacy costs.

Research design and methods: This study used data from non-randomized inpatient retrospective charts from three acute care inpatient mental health facilities. The final pooled sample included 327 patients, of which 120 received risperidone, 153 received olanzapine, and 54 received quetiapine. Medication cost was defined as the average wholesale price (AWP) as listed in the 2001 ‘Red Book’. Propensity scoring methodology and multinomial regression were employed to reduce treatment selection bias.

Results: The observed mean daily antipsychotic drug doses were 4.45?mg (SD 2.44) for risperidone, 14.04?mg (SD 5.55) for olanzapine, and 350.33?mg (SD 228.24) for quetiapine. The corresponding mean daily drug costs were $7.66(SD $4.20) for risperidone, $8.11 (SD $5.29) for quetiapine and, $12.10 (SD $4.79) for olanzepine. Numbers adjusted for treatment selection bias show that the average daily total pharmacy cost of risperidone was $4.35 lower than olanzapine (?p < 0.001) and $1.41 lower than quetiapine (?p = 0.38). The adjusted average daily pharmacy cost of olanzapine was $4.02 higher than quetiapine (?p < 0.001). After statistical adjustment there were no significant differences between study drugs in terms of length of stay or patient functioning.

Conclusion: This study provides the first US comparison of medication utilization patterns and pharmacy costs for olanzapine, risperidone, and quetiapine administered in acute mental health care inpatient settings. While this study did not estimate the full economic value of the three antipsychotics in these inpatient settings, it demonstrated that the mean daily costs for risperidone were lower than the mean daily costs for olanzapine (?p < 0.001) and quetiapine although the later difference was not statistically significant (?p = 0.38).