Overuse of Dosulepin-Prothiaden in S

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Overuse of Dosulepin-Prothiaden in SM

• Dr Nora Gribbin
• Consultant Psychiatrist Medical
  Psychotherapist, MRCPsych.
• Cognitive Behaviour Therapist
• DipCBT(Oxf), Acc. Member BABCP.

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GP meeting 22nd June 2011

• Medications ManagementTrustSM
• Audit of Dosulepin prescribing
• Practice at variance with guidelines
• What to do?
• Handout guidance

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Medication Management

• DTC Drugs Therapeutic Committee
• Chief Pharmacist, Medical Director, Chair
  Deputy Chair Borough reps.
• MHIPF Mental Health Interface Prescribing Forum
  
• Trust Pharmacists and SM Lead, Brigitte Van Der
  Zanden (practice support)
• Consultant Psychiatrist representatives incl, Dr.
  Nora Gribbin from DTC
• GP Dr. Paul Alford and Mark Robertson, joint
  commissioning
• Trust Formulary new drugs
• Off label prescribing list
• MHIPF shared care policy
• Practice Support Pharmacy

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1987 to 2011

• Tricyclics prescribed widely
• Advent of SSRIs
• Sutton South CMHT pts on Dosulepin
• 2007 NICE
• MRHA -Drug Safety Update Dec 2007 Vol 1 Issue 5
  7
• 2009 NICE
• Carshalton CMHT pts on Dosulepin

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MRHA - Drug Safety Update Dec 2007 Vol 1 Issue
5 7

• Dosulepin has a small margin of safety between
  the (maximum) therapeutic dose and potentially
  fatal doses. Use in new patients should be
  avoided where necessary, only specialist-care
  prescribers should start treatment for patients
  who have not previously received dosulepin, and
  prescribers should limit the amount issued per
  prescription.

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MRHA - Drug Safety Update Dec 2007 Vol 1 Issue
5 7

• To reduce the risk of fatal overdose, dosulepin
  has been available only in child-resistant
  blister packs since November 2007
• Pack sizes have been reduced to 2 weeks and a
  months supply

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SM Dosulepin prescribed itemsMarch 2010
February 2011
Individual practice results
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NICE clinical guidelines 90 and 91 (update of 23)
2009
When prescribing drugs other than SSRIs, take
into account the increased likelihood of the
person stopping treatment because of side
effects, and the consequent need to increase the
dose gradually, with venlafaxine, duloxetine and
TCAs the specific cautions, contraindications
and monitoring requirements for some drugs that
non-reversible monoamine oxidase inhibitors
(MAOIs, such as phenelzine), combined
antidepressants (see page 21) and lithium
augmentation of antidepressants (see pages
2122) should normally be prescribed only by
specialist mental health professionals that
dosulepin should not be prescribed.
Choosing an antidepressant see page 18
Issue date October 2009
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NICE clinical guidelines 90 and 91 (update of 23)
2009

• Switching and combining antidepressants
• When reviewing treatment after an inadequate
  response to initial pharmacological
  interventions
• check adherence to, and side effects from,
  initial treatment
• increase the frequency of appointments
• be aware that using a single antidepressant is
  usually associated with a lower side-effect
  burden
• consider reintroducing treatments that have
  been inadequately delivered or adhered to,
  including increasing the dose or switching
  antidepressants.
• When switching antidepressants, consider
• initially, a different SSRI or a better
  tolerated newer-generation antidepressant
• subsequently, an antidepressant of a different
  class that may be less well tolerated (such as
  venlafaxine, a TCA or an MAOI).
• Do not switch to, or start, dosulepin.

Page 21- Sequencing treatments after an
inadequate response
Issue date October 2009
10
NICE clinical guidelines 90 and 91 (update of 23)
2009

• That dosulepin should not be prescribed.
• Do not switch to, or start, dosulepin.

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Dosulepin prescribing in SM, Total ADQ per Star
PU March 2010 - February 2011
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What to do!

• Dont start dosulepin
• Identify who is on it
• Long term or recent - why?
• Do not stop abruptly
• Be aware of discontinuation and withdrawal
  symptoms
• Can it be withdrawn?

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Addressing Dosulepin Prescribing

• Discuss with the patient
• Do a Cost Benefit Analysis
• Discontinuation / Continuing / Switching
• Consider Promethiazine for night sedation
• Reduce cautiously
• Switching - reduce with cross tapering
• Continuing - monitor

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If Continuation Therapy is indicated for
Recurrent Depression U can Switch
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MRHA - Drug Safety Update Dec 2007 Vol 1 Issue
5 7

• A limited number of tablets should be prescribed
  to reduce the risk of overdose for all patients,
  especially those at risk of suicide
• A maximum prescription equivalent to 2 weeks
  supply of 75 mg per day should be considered in
  patients with increased risk factors for suicide
  at initiation of treatment, during any dose
  adjustment, and until improvement occurs
• Concomitant medicines that may increase the risk
  of toxicity associated with dosulepin should be
  avoided
• There is no immediate need to change treatment
  for established patients
• Patients should be advised to store tablets
  securely, out of sight and reach of children
• In cases of overdose, patients should seek
  immediate medical attention

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Examples of medicines to avoid during dosulepin
use. DSU Dec 07 vol 1 5.7

• alcohol general anaesthetics opioid analgesics
  anti-arrhythmics moxifloxacin SSRIs MAOIs
  sedating antihistamines antipsychotics
  anxiolytics hypnotics atomoxetine diltiazem
  verapamil disulfiram dopaminergics lithium
  pentamidine isethionate sibutramine and
  sympathomimetics

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If Continuation Therapy is indicated for
Recurrent Depression
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Handouts available

• Drug Safety Update Dec 2007 Vol 1 Issue 5 7
• Guidance to address Dosulepin Prescribing

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Best Star Psu practices

• Vineyard Hill
• Figges
• Riverhouse
• Wandle Valley