Antipsychotic Prescribing and Recent Research

1
Antipsychotic Prescribing and Recent Research

• George Parker, MD
• Medical Director,
• Indiana Division of Mental Health Addiction

2
A Brief History

• Chlorpromazine was the first antipsychotic
  approved by the FDA, in 1954
• Many typical antipsychotics followed
• Clozapine was FDA-approved in 1989
• Several atypical antipsychotics followed
• Currently on the US market
• Eight typical antipsychotics (all generic)
• Seven atypical antipsychotics (one generic)

3
How do They Compare?

• Atypical antipsychotics have been marketed
  aggressively from the beginning, and have become
  blockbuster drugs, generating gt1 billion in
  annual revenue
• Olanzapine 4.36 billion
• Risperidone 4.2 billion
• Quetiapine 3.4 billion
• Clozapine not even in top 10 for manufacturer

4
Industry Marketing

• Pharmaceutical representatives are very effective
  at changing prescribing patterns
• In 2005, there were 100,000 employed in the US
• One for every 2.5 targeted physicians
• Annual cost of 330,000 per specialty sales rep
• Average annual marketing costs for a specialty
  drug were 25 million (2004)

5
How do They Compare?

• Research on the utility of atypical
  antipsychotics was largely industry-funded
• Rarely compared one atypical to another
• Compared atypical to typical under conditions
  that generally favored the atypical

6
Government-Funded Studies

• Clinical Antipsychotic Trials of Intervention
  Effectiveness (CATIE)
• 42 million study funded by the National
  Institutes of Mental Health (NIMH), starting in
  1999
• Compared the available atypical antipsychotics to
  each other and to one typical antipsychotic
• The first large, well-designed study to directly
  compare the atypical antipsychotics to each other
  and to typical antipsychotics

7
CATIE

• Multiple publications to date, addressing a
  variety of important questions about
  antipsychotic effects
• Clinical utility, measured by time on the
  medication before a change
• Impact of changing/switching antipsychotics
• Role in patients with dementia
• Impact of cognition in schizophrenia
• Cost-effectiveness

8
How Do We Use CATIE?

• Translation of research into practice is not
  easy, because changing the prescribing pattern of
  an individual physician is not simple
• Internal process
• Pharmacy utilization management tools offer one
  way to change prescribing patterns
• External process

9
Pharmacy Utilization Management

• Available tools
• Dispensing limits (hard and soft)
• Preferred drug lists, or formularies
• Polypharmacy
• Generic substitution
• Cost sharing (co-pays)
• High cost management
• Prior authorization underlies all of these tools

10
Prior Authorization

• The prescriber must seek permission from an
  agency to prescribe an otherwise excluded
  medication
• Often accomplished by phone, based on scripted
  questions
• PA personnel may not be health care professionals
• May require submission of records
• Generally perceived as an onerous burden

11
Summary

• CATIE, and other government-funded studies, form
  an important data base for assessing the utility
  of psychiatric medications in clinical practice
  and for developing strategies to make informed
  choices about the effective use of limited
  resources