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Letters to the Editor Letters to the Editor Letters to the Editor © Copyright 2001 Physicians Postgraduate Press, Inc. Cost Savings With namic effects in patients who are already receiving other sedat- Intramuscular Anticholinergics ing agents and/or in the elderly, who may be more sensitive to these side effects. This intervention is easily implemented, does Sir: With the advent of atypical antipsychotics, novel anti- not appear to compromise patient care, and results in modest cost savings. convulsant agents, and selective serotonin reuptake inhibitors, the pharmacotherapy of psychiatric disorders has changed tre- mendously in the last decade. Although these newer medica- REFERENCES tions are generally better tolerated, and, in some cases, lessen associated costs of more frequent hospitalizations, they have 1. Bult J, Schiff G, Wisniewski M. Sertraline tablet splitting program. greatly impacted hospital pharmacy budgets. With few of these Hosp Pharm 1999;34:996–999 newer medications available generically, there is little opportu- 2. Holloman L, Marder S. Management of acute extrapyramidal effects induced by antipsychotic drugs. Am J Health Syst Pharm nity to decrease medication costs except Onein interventions personal such copy as may be printed 1 1997;54:2461–2477 tablet splitting. 3. Stanilla J, Simpson G. Treatment of extrapyramidal side effects. In: In an effort to reduce costs at our institution, we recently Schatzberg AF, Nemeroff CB, eds. Textbook of Psychopharmacology. identified high-use, high-cost items. As a result, one initiative 2nd ed. Washington, DC: American Psychiatric Press; 1998:349–369 we undertook was a policy of substituting generic parenteral 4. Tonda ME, Guthrie SK. Treatment of acute neuroleptic-induced diphenhydramine, 25 mg, for parenteral benztropine, 1 mg, movement disorders. Pharmacotherapy 1994;14:543–560 for the treatment and/or prophylaxis of antipsychotic-induced extrapyramidal symptoms (EPS). Significantly, parenteral John S. Markowitz, Pharm.D. benztropine is unavailable generically, but was the medication Stephen McLeod-Bryant, M.D. of choice at our institution for acute EPS or prophylaxis. Fur- Cherry Wyant Jackson, Pharm.D. ther, cost differences between the 2 products were substantial Medical University of South Carolina at $7.30 per single-use 2-mL glass ampul of benztropine Charleston, South Carolina (1 mg/mL) versus $0.40 per 2-mL multiuse vial of diphenhydra- mine (50 mg/mL). Although we could locate no controlled clini- cal efficacy trials of benztropine versus diphenhydramine for EPS, the use of both agents is widely accepted in the treatment Problems With Ensuring a Double Blind of acute dystonic reactions and pseudoparkinsonism.2–4 Diphen- hydramine is generally regarded as the more sedating agent as a Sir: We read with interest the article by Zanardi et al.1 evalu- result of its antihistamine effects, but this may be beneficial in ating the effectiveness of venlafaxine versus fluvoxamine in the some patients.3 Further, some patients may respond more rap- treatment of delusional depression. Delusional depression, as idly to diphenhydramine.4 the authors point out, is a difficult condition to treat with the The project was implemented via a joint memorandum to all limited treatment options available to clinicians. New treatment medical staff from the medical director and clinical coordinator trials such as that reported in this study are always welcome. We for pharmacy services at the institution that outlined the project have, however, 2 concerns about the design used by the authors and potential savings. The medical staff was encouraged to vol- that may have compromised the integrity of the blind in their untarily comply with the effort. study. Compliance with the project was excellent and almost im- Firstly, as the authors indicate, venlafaxine and fluvoxamine mediate. No adverse events or efficacy problems were reported work on different neurotransmitters. Consequently, the 2 drugs during the year that intramuscular diphenhydramine was used. have different side effect profiles, namely, sustained hyperten- Our hospital saved approximately $9000 in drug costs the first sion, dizziness, delayed ejaculation, and somnolence are more year, or $6.90 per dose, with the change to diphenhydramine. common with venlafaxine2 and gastrointestinal symptoms, mal- This savings is expected to continue on an annual basis. aise, sedation, tremor, and exacerbation of anxiety features are Our clinical findings are limited since we did not perform a associated with fluvoxamine.3 The authors report that the side rigorous assessment of individual differences in observed or effects were rated by “trained psychiatrists” using the Dosage perceived EPS in patients treated with one agent versus the Records and Treatment Emergent Symptoms Scale (DOTES). other. Nonetheless, as a result of our experience and the known Some of the side effects outlined above were experienced by effectiveness of both agents, we believe clinicians can consider study participants, but the authors do not report the drugs with switching from intramuscular benztropine to diphenhydramine which they were associated. The blind of the study might have for the treatment or prophylaxis of antipsychotic-induced EPS. been broken because side effect profiles do provide significant However, since diphenhydramine may be more sedating than clues about the drug being tried.4 For instance, one could specu- benztropine, caution is advised to avoid additive pharmacody- late, even though the authors do not report, that the patient who J Clin Psychiatry 62:4, April 2001 295 Letters to the Editor dropped out of the study owing to a marked increase in blood Regarding the second and last concern that Drs. Kumar and pressure was likely to be on venlafaxine treatment. Two inter- Oakley-Browne had about the description of medication dispen- ventions have been reported to be helpful in this regard4: (1) one sation, we cannot help agreeing with them. In fact, being aware blinded psychiatrist monitors the therapeutic response and pos- of the importance of ensuring that the dispensation of medica- sible toxicity and another psychiatrist, who is not blinded, re- tions did not break the blind, we carefully followed these rules: ceives reports from the first psychiatrist and the laboratory and the external appearance of the capsules was identical for size, adjusts the dosage according to the study protocol; (2) the psy- consistency, and color; the number of capsules administered chiatrists are asked to guess what medication each patient is re- was the same in the 2 groups (1 capsule daily for the first 3 days ceiving. If the success rate of having a correct guess is higher and then 2 capsules daily for each patient); the time of adminis- than chance, then one could say that the blind is broken. tration for the 2 treatments during the day was the same (1 cap- Secondly, some important details about medication dispen- sule after dinner on the first 3 days with the addition of the sation are missing© Copyright that are important in 2001 ensuring a Physiciansdouble blind. second Postgraduate capsule after breakfast Press,from the fourth Inc. day on); and These include the number of tablets patients were having to medication dispensation was carried out by a member of the take, the external appearance of the tablets, and who dispensed nursing staff. Given these precautions, we feel confident in say- them to the patients.4 A conventional way to ensure blinding ing that our trial was not affected at all by such limitations. in studies in which patients have to take different numbers of In every randomized controlled study we carry out, we stick tablets owing to varying dose strengths is called the “double- to the suggestions so clearly outlined in the CONSORT state- placebo method.”4 Each group receives an identical number of ment.4 The problem arising from the full description of such tablets made by combining active medication and placebo. guidelines is the need of more space than is usually available in The findings of this pilot study should be interpreted in light scientific journals. of these factors, which could have been best outlined in the dis- cussion of the limitations of the study. REFERENCES REFERENCES 1. Zanardi R, Franchini L, Serretti A, et al. Venlafaxine versus fluvox- One personal copy may beamine printed in the treatment of delusional depression: a pilot double-blind 1. Zanardi R, Franchini L, Serretti A, et al. Venlafaxine versus fluvox- controlled study. J Clin Psychiatry 2000;61:26–29 amine in the treatment of delusional depression: a pilot double-blind 2. Markham Brown T, Stoudemire A. Psychiatric Side Effects of controlled study. J Clin Psychiatry 2000;61:26–29 Prescription and Over-the-Counter Medications. Washington, DC: 2. Mackay FR, Dunn NR, Martin RM, et al. Newer antidepressants: American Psychiatric Press; 1998 a comparison of tolerability in general practice. Br J Gen Pract 1999; 3. Medscape DrugInfo. Available at: http:// 49:892–896 www.promini.medscape.com/drugdb/search.asp. Accessed January 8, 3. Edwards JG, Anderson I. Systematic review and guide to selection of 2000 selective serotonin re-uptake inhibitors. Drugs 1999;57:507–533 4. CONSORT Group. Improving the quality of reporting of randomized 4. Spiker B. Guide to Clinical Trials. New York, NY: Raven Press; 1991 controlled trials: the CONSORT statement. JAMA 1996;276:637–639 Shailesh Kumar, M.R.C.Psych., M.Phil. Raffaella Zanardi, M.D. Lakeland Health Limited David Rossini, M.D. Rotorua, New
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