Are specific initiatives required to enhance prescribing of generic atypical antipsychotics in Scotland?: International implications

Ongoing initiatives within the Scottish National Health Service to affect the prescribing of selective serotonin reuptake inhibitors and their influence

Aim: Increasing use of selective serotonin-reuptake inhibitors (SSRIs) in Scotland, coupled with safety concerns with some SSRIs, and the increasing availability of generic SSRIs, have resulted in multiple initiatives to improve the quality and efficiency of their prescribing in Scotland. Our aim is to assess their influence to provide future direction. Materials & methods: The prescription costs analysis database was used to document utilization and expenditure on SSRIs between 2001 and 2017 alongside documenting the initiatives. Results: Multiple interventions over the years increased international nonproprietary name prescribing up to 99.9% lowering overall costs. This, coupled with initiatives to limit escitalopram prescribing due to concerns with its value, resulted in a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilization. Safety warnings resulted in a significant reduction in the prescribing of paroxetine, citalopram and escitalopram alongside a significant increase in sertraline Conclusion: Multiple initiatives have increased the quality and efficiency of SSRI prescribing in Scotland providing direction to others.

Trends in the prescribing of antipsychotic medicines in Pakistan: implications for the future

Introduction and objectives: There is a paucity of antipsychotic prescribing and utilization data in Pakistan that needs addressing, especially with issues of availability, affordability, gender differences, and domestic violence, to develop pertinent strategies. The objective of this study was to address these issues by describing current antipsychotic utilization patterns in Pakistan among adult patients attending tertiary care hospitals and private practitioners.Methods: A three staged approach was used including (1) assessment of total antipsychotic utilization, expenditure, and costs per unit between 2010 and 2015, (2) an in-depth retrospective study of prescribing patterns, including co-morbidities among representative hospital patients in Pakistan, and (3) assessment of the quality of prescribing against WHO targets.Results: Total use of antipsychotics increased 4.3-fold and the cost/unit increased by 13.2% during the study period. Risperidone and olanzapine were the most prescribed antipsychotics with more limited use of other typical and atypical antipsychotics. The number of medicines per encounter was 4.56. Prescription using generic instead of brand names was 21.4%. Seven per cent were prescribed more than one antipsychotic concurrently.Conclusion: There has been an appreciable increase in antipsychotic utilization in recent years in Pakistan, especially atypical antipsychotics, with little polypharmacy. Ongoing utilization of typical antipsychotics may be due to comorbidities such as diabetes and cardiovascular disease. Issues of international non-proprietary name prescribing need investigating along with the high number of medicines per encounter and gender inequality.

Costs in the Treatment of Schizophrenia in Adults Receiving Atypical Antipsychotics: An 11-Year Cohort in Brazil

BACKGROUND

Schizophrenia is associated with significant economic burden. In Brazil, antipsychotic drugs and outpatient and hospital services are provided by the Brazilian National Health System (SUS) for patients with schizophrenia. However, few studies capture the cost of managing these patients within the Brazilian NHS. This is important to appraise different management approaches within universal healthcare systems.

OBJECTIVE

Our objective was to use real-world data to describe the costs associated with the treatment of schizophrenia in adults receiving atypical antipsychotics in Brazil from 2000 to 2010.

METHODS

We integrated three national databases for adult patients with schizophrenia receiving one or more atypical antipsychotics. We assessed only direct medical costs and the study was conducted from a public-payer perspective. A multivariate log-linear regression model was performed to evaluate associations between costs and clinical and demographic variables.

RESULTS

We identified 174,310 patients with schizophrenia, with mean ± standard deviation (SD) annual costs of $US1811.92 ± 284.39 per patient. Atypical antipsychotics accounted for 79.7% of total costs, with a mean annual cost per patient of $US1578.74 ± 240.40. Mean annual costs per patient were $US2482.90 ± 302.92 for psychiatric hospitalization and $US862.96 ± 160.18 for outpatient psychiatric care. Olanzapine was used by 47.7% of patients and represented 62.8% of the total costs of atypical antipsychotics. Patients who used clozapine had the highest mean annual cost per patient for outpatient psychiatric care and psychiatric hospitalization.

CONCLUSIONS

Atypical antipsychotics were responsible for the majority of the schizophrenia treatment costs, and psychiatric hospitalization costs were the highest mean annual cost per patient. Authorities should ensure efficient use of atypical antipsychotics and encourage outpatient psychiatric care over psychiatric hospitalization where possible.

Distribution and trends in outpatient utilization of generic versus brand name psychopharmaceuticals during a ten-year period in Croatia

BACKGROUND

Drug costs increasingly pose a burden upon the otherwise inadequate health care resources and rational drug utilization is an important segment of every national health policy. Optimal patient care should be the goal of rational pharmacotherapy, whereby the economic burden of treatment is just one of the elements to be considered on choosing appropriate therapy.The aim of this study was to determine distribution and trends in the outpatient utilization of generic versus brand name psychopharmaceuticals and to evaluate the rationality of prescribing psychopharmaceuticals during a ten-year period.

METHODS

Using the World Health Organization Anatomical-Therapeutic-Chemical classification/Defined Daily Doses (ATC/DDD) methodology, the number of DDD was calculated from data collected from pharmacies on the number and size of drug packages. The ratio of generic and brand name drug costs served as an indicator on assessing the rationality of drug utilization.

RESULTS

Total cost for psychopharmaceuticals increased by 20.1%, more for brand name than for generic agents (32.7% vs. 7.4%). The highest share of generic psychopharmaceuticals as compared with brand name drugs according to DDD per 1000 inhabitants per day (DDD/1000/day) was in the group of psycholeptics (83.6% in 2001 vs. 82.2% in 2010), most in hypnotics and sedatives, and least in antipsychotics. The share of generic psychopharmaceuticals in total drug utilization according to financial indicators decreased by 9.6% and according to DDD/1000/day by 12%. The greatest decrease was in antidepressants, i.e. by 33.8% according to financial indicators and by 46% according to DDD/1000/day; and in antipsychotics by 30.9% according to DDD/1000/day, while showing an increase by 8.5% according to financial indicators. In the therapeutic subgroup of mood stabilizers, the share of generic drugs in total drug utilization declined by 32% according to DDD/1000/day, but increased by 25.1% according to financial indicators.

CONCLUSIONS

The lack of uniform national guidelines and the still strong impact of pharmaceutical industry marketing continue favoring the rise in prescribing brand name antidepressants and antipsychotics. Depression, schizophrenia and bipolar diseases are complex diseases. As a result, specific measures are needed to encourage the prescribing of generic psychopharmaceuticals.

Can authorities appreciably enhance the prescribing of oral generic risperidone to conserve resources? Findings from across Europe and their implications

BACKGROUND

Generic atypical antipsychotic drugs offer health authorities opportunities for considerable savings. However, schizophrenia and bipolar disorders are complex diseases that require tailored treatments. Consequently, generally there have been limited demand-side measures by health authorities to encourage the preferential prescribing of generics. This is unlike the situation with hypertension, hypercholaesterolaemia or acid-related stomach disorders.The objectives of this study were to compare the effect of the limited demand-side measures in Western European countries and regions on the subsequent prescribing of risperidone following generics; to utilise the findings to provide future guidance to health authorities; and where possible, to investigate the utilisation of generic versus originator risperidone and the prices for generic risperidone.

METHODS

Principally, this was a segmented regression analysis of retrospective time-series data of the effect of the various initiatives in Belgium, Ireland, Scotland and Sweden following the introduction of generic risperidone. The study included patients prescribed at least one atypical antipsychotic drug up to 20 months before and up to 20 months after generic risperidone. In addition, retrospective observational studies were carried out in Austria and Spain (Catalonia) from 2005 to 2011 as well as one English primary care organisation (Bury Primary Care Trust (PCT)).

RESULTS

There was a consistent steady reduction in risperidone as a percentage of total selected atypical antipsychotic utilisation following generics. A similar pattern was seen in Austria and Spain, with stable utilisation in one English PCT. However, there was considerable variation in the utilisation of generic risperidone, ranging from 98% of total risperidone in Scotland to only 14% in Ireland. Similarly, the price of generic risperidone varied considerably. In Scotland, generic risperidone was only 16% of pre-patent loss prices versus 72% in Ireland.

CONCLUSION

Consistent findings of no increased prescribing of risperidone post generics with limited specific demand-side measures suggests no 'spillover' effect from one class to another encouraging the preferential prescribing of generic atypical antipsychotic drugs. This is exacerbated by the complexity of the disease area and differences in the side-effects between treatments. There appeared to be no clinical issues with generic risperidone, and prices inversely reflected measures to enhance their utilisation.

Behaviour change interventions to promote prescribing of generic drugs: a rapid evidence synthesis and systematic review

OBJECTIVE

To summarise evidence on the effectiveness of behaviour change interventions to encourage prescribing of generic forms of prescription drugs where clinically appropriate in the UK National Health Service (NHS) and similar settings.

DESIGN

Systematic review.

SEARCH STRATEGY

We conducted a rapid evidence synthesis in two stages: First, we searched databases, such as the Cochrane Database of Systematic Reviews (CDSR) and Database of Abstracts of Reviews of Effects (DARE), for systematic reviews of interventions that reported outcomes related to utilisation of generic drugs. In the second stage, we searched several databases including MEDLINE and EMBASE to identify primary studies of any interventions not covered by systematic reviews.

DATA EXTRACTION AND QUALITY ASSESSMENT

Data were extracted into a standardised data extraction form. Standardised quality assessment tools were used to assess study quality. Two reviewers were involved in data extraction and quality assessment.

RESULTS

10 reviews were included for the initial evidence synthesis, but most were of limited usefulness to our focused review question. One review evaluated the effect of prescribing policies using financial incentives and showed an increase in generic prescribing. Thirteen primary studies of other interventions were included for the rapid review. Two studies showed an increase in percentage of overall generic prescribing with an educational intervention; two studies showed an improvement in generic prescribing rates when physicians collaborated with pharmacists, though in one study this was not statistically significant; two US studies showed improvements in generic prescribing with electronic prescribing. Five out of seven studies showed positive results with multifaceted interventions.

CONCLUSIONS

The existing evidence remains insufficient to determine which behaviour change intervention or combination of interventions is most effective due to methodological weaknesses and conflicting results. Based on the evidence, financial incentives with educational intervention and audit/feedback look promising but decision-makers should take into account the practicality and costs of the interventions before implementation.

Torsadogenic risk of antipsychotics: combining adverse event reports with drug utilization data across Europe

Background

Antipsychotics (APs) have been associated with risk of torsade de Pointes (TdP). This has important public health implications. Therefore, (a) we exploited the public FDA Adverse Event Reporting System (FAERS) to characterize their torsadogenic profile; (b) we collected drug utilization data from 12 European Countries to assess the population exposure over the 2005-2010 period.

Methods

FAERS data (2004-2010) were analyzed based on the following criteria: (1) ≥4 cases of TdP/QT abnormalities; (2) Significant Reporting Odds Ratio, ROR [Lower Limit of the 95% confidence interval>1], for TdP/QT abnormalities, adjusted and stratified (Arizona CERT drugs as effect modifiers); (3) ≥4 cases of ventricular arrhythmia/sudden cardiac death (VA/SCD); (4) Significant ROR for VA/SCD; (5) Significant ROR, combined by aggregating TdP/QT abnormalities with VA and SCD. Torsadogenic signals were characterized in terms of signal strength: from Group A (very strong torsadogenic signal: all criteria fulfilled) to group E (unclear/uncertain signal: only 2/5 criteria). Consumption data were retrieved from 12 European Countries and expressed as defined daily doses per 1,000 inhabitants per day (DID).

Results

Thirty-five antipsychotics met at least one criterium: 9 agents were classified in Group A (amisulpride, chlorpromazine, clozapine, cyamemazine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone). In 2010, the overall exposure to antipsychotics varied from 5.94 DID (Estonia) to 13.99 (France, 2009). Considerable increment of Group A agents was found in several Countries (+3.47 in France): the exposure to olanzapine increased across all Countries (+1.84 in France) and peaked 2.96 in Norway; cyamemazine was typically used only in France (2.81 in 2009). Among Group B drugs, levomepromazine peaked 3.78 (Serbia); fluphenazine 1.61 (Slovenia).

Conclusions

This parallel approach through spontaneous reporting and drug utilization analyses highlighted drug- and Country-specific scenarios requiring potential regulatory consideration: levomepromazine (Serbia), fluphenazine (Slovenia), olanzapine (across Europe), cyamemazine (France). This synergy should be encouraged to support future pharmacovigilance activities.

Generic atypical antipsychotic drugs in Belgium: their influence and implications

Introduction: Generic atypical antipsychotic drugs should be a focus of attention given their expenditure. However, there is a recognized need to tailor treatments. There were no specific measures in Belgium to enhance the prescribing of oral risperidone following generics in January 2008. Prescribing restrictions have remained for long-acting risperidone injections throughout. Objective: Assess changes in risperidone utilization before and after oral generics were reimbursed, as well as the utilization and expenditure of the various risperidone preparations. Method: Principally a retrospective observational study and interrupted time series design. Results: As expected, no increased utilization of oral risperidone after generics. Both originator and generic oral risperidone prescribed, with the originator reducing its price. Generic risperidone was 59% below prepatent loss prices by September 2012. Conclusion: Authorities cannot rely on a ‘spill over’ of learning from other disease areas to affect changes in physician prescribing habits. Specific measures are needed to encourage generic risperidone where appropriate. However, their influence will be limited by the complexity of the disease area.

Changes in the utilization of venlafaxine after the introduction of generics in Sweden

BACKGROUND

There has been an appreciable increase in the prescribing efficiency of proton pump inhibitors, statins, and renin-angiotensin inhibitor drugs in Sweden in recent years. This has been achieved through multiple reforms encouraging the prescription of generics at low prices versus patented drugs in the same class. Generic venlafaxine also presents an opportunity to save costs given the prevalence of depression. However, depression is more complex to treat, with physicians reluctant to change prescriptions if patients are responding to a particular antidepressant.

OBJECTIVES

We assessed (a) changes in the utilization pattern of venlafaxine versus other newer antidepressants before and after the availability of generic venlafaxine and before and after the initiation of prescription restrictions for duloxetine limiting its prescription to refractory patients, (b) utilization of generic versus original venlafaxine after its availability, and (c) price reductions for generic venlafaxine and the subsequent influence on total expenditure on newer antidepressants over time.

METHODOLOGY

We performed interrupted time series analysis of changes in monthly reimbursed prescriptions using defined daily doses (DDDs) of patients dispensed at least one newer antidepressant from January 2007 to August 2011. DDDs was defined as the average maintenance dose of a drug when used in its major indication in adults. This included 19 months after the availability of generic venlafaxine and before initiation of prescription restrictions for duloxetine to 13 months after prescription restrictions. Total expenditure and expenditure/DDD for venlafaxine were measured over time.

RESULTS

No appreciable change in the utilization pattern for venlafaxine was observed after generic availability when no appreciable demand-side activities by the regions (counties) were implemented to encourage its use. The utilization of venlafaxine significantly increased after prescription restrictions for duloxetine. Generic venlafaxine was dispensed once available, reaching 99.6 % of total venlafaxine (DDD basis) by August 2011. There was an appreciable fall in expenditure for newer antidepressants in Sweden after generic venlafaxine despite increased utilization, helped by a 90 % reduction in expenditure/DDD for venlafaxine by the end of the study versus prepatent loss prices.

CONCLUSION

Multiple demand-side measures are needed to change physician prescribing habits. Authorities should not rely on a spillover effect between drug classes to effect change. Limited influence of prescription restrictions on the subsequent utilization of duloxetine reflects the complexity of this disease area. This is exacerbated by heterogeneous indications for duloxetine.