- Email: [email protected]
An overview on the trends of typical and atypical antipsychotic drugs’ use in Bangladesh
Asian Journal of Psychiatry 4 (2011) 71–72
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Letter to Editor An overview on the trends of typical and atypical antipsychotic drugs’ use in Bangladesh The article entitled ‘An overview on the trends of typical and atypical antipsychotic drugs’ use in Bangladesh’ depicts a picture of antipsychotic drugs’ use pattern of the country which was done through a prescription survey research. The typical and atypical antipsychotic drugs work on different types of dopamine and serotonin receptors by mainly antagonizing but in some cases agonizing the receptors (Herbert, 2002). The atypical agents like clozapine, olanzapine, and risperidone are more advantageous compared to typical antipsychotic agents in terms of both efficacy and safety profile to the patients (David and Lewis, 2002). This survey was performed from April to the end of July of 2009. The prescription profiles of 384 out patients were collected for analysis and were duly recorded. A questionnaire format was developed before the survey study and the necessary information to complete the questionnaire not clearly mentioned in the prescriptions was taken from the attendants of the patients. All the percentage was calculated based on total number of patients (Table 1). The data of patients receiving antipsychotic, antidepressants, anxiolytic, anticholinergic drugs were all pooled together. There were some very interesting findings for these drugs’ use pattern. In one key finding, it has observed that most of the psychiatric patients were receiving atypical antipsychotics (61.46%) – either alone or in combination and this class is dominant in use in comparison to the typical antipsychotic drugs. Even single atypical antipsychotic drug was received by a large number of patients (23.44%) in comparison to typical antipsychotic single agent use (8.33%). In order to compare the obtained data with those of other countries, we collected the data of few other countries’ psychiatry practice trends too. The data of five countries show that, atypical Table 1 Trends of antipsychotic drugs’ use in Bangladesh (single antipsychotic or in combination). The most common trend of antipsychotic use (polypharmacy) Feature
Only Single typical antipsychotic Only Single atypical antipsychotic Single Typical + Atypical antipsychotic Single typical + Atypical + Anticholinergic Single typical + Atypical + Anticholinergic + Anxiolytic 2 or more typical + 1 Typical 2 Typical + 1 Atypical + Procyclidine 2 or more typical + Atypical + Procyclidine + Anxiolytic 2 or more typical + Atypical + Procyclidine + Antiepileptic
Use in patients Number of patients
% of patients
32 90 80 74 44
8.33 23.44 20.83 19.27 11.46
42 40 20
10.94 10.42 5.21
8
2.08
antipsychotic drugs are prescribed to a great extent almost everywhere, e.g. 18% in UK, 42% in Italy, 62% in USA but less than 2% in Palestine (Sweileh et al., 2004). Molecular preference to choose an antipsychotic drug for the psychiatric patients was an important conclusion drawn from the survey study. In Bangladesh, Haloperidol (23.96% user) and Olanzapine (28.65% user) are the most widely used molecules from typical and atypical antipsychotic class of drugs respectively. These two drugs are more prevalent in use than other drugs belonging to the corresponding class of antipsychotic drugs. It was found that different classes of drugs like anticholinergic drugs, antiepileptic drugs, antidepressants and anxiolytic drugs were frequently combined with typical and atypical antipsychotic drugs quite logically (Veronese et al., 2007; Okasha, 2004; Ghaemi and Thase, 2002). Besides these, some other types were also used like Vitamin preparations (e.g. single or multi vitamin), NSAIDs or other analgesics, antiulcerants and cardiovascular drugs when comorbid diseases exist in patients. Procyclidine (anticholinergic drug) was used to treat Parkinsonism due to its anti-cholinergic action (Todorvic et al., 2003). Procyclidine was used in the highest percentage among the patients taking antipsychotic drugs (72.92%). One of the most important findings was ‘Polypharmacy’ which means ‘many drugs’ (Rittmannsberger et al., 1999) and it is very common in Bangladesh. The commonly used combination patterns are Single typical + Atypical + Anticholinergic (19.27%), Single typical + Atypical + Anticholinergic + Anxiolytic (Benzodiazepine) (11.46%), 2 Typical + 1 Atypical + Procyclidine (10.42%), 2 or more typical + Atypical + Procyclidine + Anxiolytic (Benzodiazepine) (5.21%) and 2 or more typical + Atypical + Procyclidine + Antiepileptic (2.08%). In spite of the common psychiatry practice trend, it is well known that polypharmacy accounts for higher rates of depression and reduced quality of life (Chumney and Robinson, 2006). In one study done in Australia, 13% of all outpatients received more than one antipsychotic medication (Keks et al., 1999). In another study in Austria, 47% of patients received prescriptions for two antipsychotic medications, and 8% received prescriptions for three medications (Rittmannsberger et al., 1999). In conclusion, atypical antipsychotic drugs are more frequently used than typical antipsychotic drugs in Bangladesh. Combination of multiple medications is the most common scenario which may exert synergistic antipsychotic efficacy but leads towards polypharmacy and reduced quality of life of psychiatric patients.
References
N.B: All the percentage was calculated in the whole number that is 384 patients. 1876-2018/$ – see front matter ß 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2010.08.012
Chumney, E.C., Robinson, L.C., 2006. The effects of pharmacist interventions on patients with polypharmacy. Pharmacy Practice 4 (3), 103–109. David, A., Lewis, M.D., 2002. Atypical antipsychotic medications and the treatment of schizophrenia. The American Journal of Psychiatry 159 (2), 177–179. Ghaemi, S.N., Thase, M.E., 2002. Role of antiepileptics and atypical antipsychotics Bipolar depression. Supplement Current Psychiatry, December Supplement, pp. 13–22.
72
Letter to Editor / Asian Journal of Psychiatry 4 (2011) 71–72
Herbert, Y. Meltzer, 2002. Mechanism of action of atypical antipsychotic drugs. Neuropsychopharmacololgy: The Fifth Generation of Progress. Keks, N.A., Altson, K., Hope, J., et al., 1999. Use of antipsychosis and adjunctive medications by an inner urban community psychiatric service. Australian and New Zealand Journal of Psychiatry 33, 896–901. Okasha, A., 2004. State of the art in the management of bipolar disorder. Arabpsynet Journal (3), 5–7. Rittmannsberger, H., Meise, U., Schauflinger, K., 1999. Polypharmacy in psychiatric treatment: patterns of psychotropic drug use in Austrian psychiatric clinics. European Psychiatry 14, 33–40. Sweileh, W., Jaradat, N., Al-Khayyat, A.A., 2004. Typical and atypical antipsychotic drug utilization in psychiatric clinic in Palestine. An-Najah University Journal for Research (Natural Sciences) 18 (1), 39–47. Todorvic, V.J., Meyenburg, A.P., Olney, J.W., Wozniak, D.F., 2003. Anti-parkinsonian agents procyclidine and ethopropazine alleviate thermal hyperalgesia in neuropathic rats. Neuropharmacology 44 (6), 739–748. Veronese, A., Garatti, M., Cipriani, A., Barbui, C., 2007. Benzodiazepine use in the real world of psychiatric practice: low-dose, long-term drug taking and low rates of treatment discontinuation. European Journal of Clinical Pharmacology 63, 867– 873.
Md. Obaidur Rahman1,* Department of Pharmaceutical Chemistry, University of Dhaka, Dhaka-1000, Bangladesh
Mohammad Ahsanul Akbar Department of Clinical Pharmacy and Pharmacology, University of Dhaka, Dhaka-1000, Bangladesh Rubina Ahamed Department of Clinical Pharmacy and Pharmacology, University of Dhaka, Dhaka-1000, Bangladesh *Corresponding
author: 295/zh/7, Rayer bazaar, Tally office, Dhanmondi, Dhaka-1209, Bangladesh. Tel.: +880 1714094139; fax: +880 028612069 E-mail address: [email protected]
1
Present address: House no-1407, Shobuzbag, Bogra Shadar Thana, Bogra, Bangladesh. 2 June 2010
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Letter to Editor An overview on the trends of typical and atypical antipsychotic drugs’ use in Bangladesh The article entitled ‘An overview on the trends of typical and atypical antipsychotic drugs’ use in Bangladesh’ depicts a picture of antipsychotic drugs’ use pattern of the country which was done through a prescription survey research. The typical and atypical antipsychotic drugs work on different types of dopamine and serotonin receptors by mainly antagonizing but in some cases agonizing the receptors (Herbert, 2002). The atypical agents like clozapine, olanzapine, and risperidone are more advantageous compared to typical antipsychotic agents in terms of both efficacy and safety profile to the patients (David and Lewis, 2002). This survey was performed from April to the end of July of 2009. The prescription profiles of 384 out patients were collected for analysis and were duly recorded. A questionnaire format was developed before the survey study and the necessary information to complete the questionnaire not clearly mentioned in the prescriptions was taken from the attendants of the patients. All the percentage was calculated based on total number of patients (Table 1). The data of patients receiving antipsychotic, antidepressants, anxiolytic, anticholinergic drugs were all pooled together. There were some very interesting findings for these drugs’ use pattern. In one key finding, it has observed that most of the psychiatric patients were receiving atypical antipsychotics (61.46%) – either alone or in combination and this class is dominant in use in comparison to the typical antipsychotic drugs. Even single atypical antipsychotic drug was received by a large number of patients (23.44%) in comparison to typical antipsychotic single agent use (8.33%). In order to compare the obtained data with those of other countries, we collected the data of few other countries’ psychiatry practice trends too. The data of five countries show that, atypical Table 1 Trends of antipsychotic drugs’ use in Bangladesh (single antipsychotic or in combination). The most common trend of antipsychotic use (polypharmacy) Feature
Only Single typical antipsychotic Only Single atypical antipsychotic Single Typical + Atypical antipsychotic Single typical + Atypical + Anticholinergic Single typical + Atypical + Anticholinergic + Anxiolytic 2 or more typical + 1 Typical 2 Typical + 1 Atypical + Procyclidine 2 or more typical + Atypical + Procyclidine + Anxiolytic 2 or more typical + Atypical + Procyclidine + Antiepileptic
Use in patients Number of patients
% of patients
32 90 80 74 44
8.33 23.44 20.83 19.27 11.46
42 40 20
10.94 10.42 5.21
8
2.08
antipsychotic drugs are prescribed to a great extent almost everywhere, e.g. 18% in UK, 42% in Italy, 62% in USA but less than 2% in Palestine (Sweileh et al., 2004). Molecular preference to choose an antipsychotic drug for the psychiatric patients was an important conclusion drawn from the survey study. In Bangladesh, Haloperidol (23.96% user) and Olanzapine (28.65% user) are the most widely used molecules from typical and atypical antipsychotic class of drugs respectively. These two drugs are more prevalent in use than other drugs belonging to the corresponding class of antipsychotic drugs. It was found that different classes of drugs like anticholinergic drugs, antiepileptic drugs, antidepressants and anxiolytic drugs were frequently combined with typical and atypical antipsychotic drugs quite logically (Veronese et al., 2007; Okasha, 2004; Ghaemi and Thase, 2002). Besides these, some other types were also used like Vitamin preparations (e.g. single or multi vitamin), NSAIDs or other analgesics, antiulcerants and cardiovascular drugs when comorbid diseases exist in patients. Procyclidine (anticholinergic drug) was used to treat Parkinsonism due to its anti-cholinergic action (Todorvic et al., 2003). Procyclidine was used in the highest percentage among the patients taking antipsychotic drugs (72.92%). One of the most important findings was ‘Polypharmacy’ which means ‘many drugs’ (Rittmannsberger et al., 1999) and it is very common in Bangladesh. The commonly used combination patterns are Single typical + Atypical + Anticholinergic (19.27%), Single typical + Atypical + Anticholinergic + Anxiolytic (Benzodiazepine) (11.46%), 2 Typical + 1 Atypical + Procyclidine (10.42%), 2 or more typical + Atypical + Procyclidine + Anxiolytic (Benzodiazepine) (5.21%) and 2 or more typical + Atypical + Procyclidine + Antiepileptic (2.08%). In spite of the common psychiatry practice trend, it is well known that polypharmacy accounts for higher rates of depression and reduced quality of life (Chumney and Robinson, 2006). In one study done in Australia, 13% of all outpatients received more than one antipsychotic medication (Keks et al., 1999). In another study in Austria, 47% of patients received prescriptions for two antipsychotic medications, and 8% received prescriptions for three medications (Rittmannsberger et al., 1999). In conclusion, atypical antipsychotic drugs are more frequently used than typical antipsychotic drugs in Bangladesh. Combination of multiple medications is the most common scenario which may exert synergistic antipsychotic efficacy but leads towards polypharmacy and reduced quality of life of psychiatric patients.
References
N.B: All the percentage was calculated in the whole number that is 384 patients. 1876-2018/$ – see front matter ß 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2010.08.012
Chumney, E.C., Robinson, L.C., 2006. The effects of pharmacist interventions on patients with polypharmacy. Pharmacy Practice 4 (3), 103–109. David, A., Lewis, M.D., 2002. Atypical antipsychotic medications and the treatment of schizophrenia. The American Journal of Psychiatry 159 (2), 177–179. Ghaemi, S.N., Thase, M.E., 2002. Role of antiepileptics and atypical antipsychotics Bipolar depression. Supplement Current Psychiatry, December Supplement, pp. 13–22.
72
Letter to Editor / Asian Journal of Psychiatry 4 (2011) 71–72
Herbert, Y. Meltzer, 2002. Mechanism of action of atypical antipsychotic drugs. Neuropsychopharmacololgy: The Fifth Generation of Progress. Keks, N.A., Altson, K., Hope, J., et al., 1999. Use of antipsychosis and adjunctive medications by an inner urban community psychiatric service. Australian and New Zealand Journal of Psychiatry 33, 896–901. Okasha, A., 2004. State of the art in the management of bipolar disorder. Arabpsynet Journal (3), 5–7. Rittmannsberger, H., Meise, U., Schauflinger, K., 1999. Polypharmacy in psychiatric treatment: patterns of psychotropic drug use in Austrian psychiatric clinics. European Psychiatry 14, 33–40. Sweileh, W., Jaradat, N., Al-Khayyat, A.A., 2004. Typical and atypical antipsychotic drug utilization in psychiatric clinic in Palestine. An-Najah University Journal for Research (Natural Sciences) 18 (1), 39–47. Todorvic, V.J., Meyenburg, A.P., Olney, J.W., Wozniak, D.F., 2003. Anti-parkinsonian agents procyclidine and ethopropazine alleviate thermal hyperalgesia in neuropathic rats. Neuropharmacology 44 (6), 739–748. Veronese, A., Garatti, M., Cipriani, A., Barbui, C., 2007. Benzodiazepine use in the real world of psychiatric practice: low-dose, long-term drug taking and low rates of treatment discontinuation. European Journal of Clinical Pharmacology 63, 867– 873.
Md. Obaidur Rahman1,* Department of Pharmaceutical Chemistry, University of Dhaka, Dhaka-1000, Bangladesh
Mohammad Ahsanul Akbar Department of Clinical Pharmacy and Pharmacology, University of Dhaka, Dhaka-1000, Bangladesh Rubina Ahamed Department of Clinical Pharmacy and Pharmacology, University of Dhaka, Dhaka-1000, Bangladesh *Corresponding
author: 295/zh/7, Rayer bazaar, Tally office, Dhanmondi, Dhaka-1209, Bangladesh. Tel.: +880 1714094139; fax: +880 028612069 E-mail address: [email protected]
1
Present address: House no-1407, Shobuzbag, Bogra Shadar Thana, Bogra, Bangladesh. 2 June 2010