Whelehans Health Blog

Medication used to treat

This is a continuation of last week’s article in which I discussed causes and symptoms of schizophrenia. Last week I described how antipsychotic drugs are the main class of medication used to treat schizophrenia and are broadly divided into two categories; older typical or newer atypical antipsychotics.

Choice of Drug

No one drug can be considered significantly better than the others, however one may be better for one individual than another. For example, some are more sedating than others so may be suitable for patients who are agitated or cannot sleep. If one does not work so well, a different one is tried until a good response occurs. A good response to antipsychotic medication occurs in about 70% of cases. For patients with only one episode of schizophrenia and remain symptom free for two years with treatment, the medication may then be discontinued slowly; closely monitored for relapse when medication is being discontinued.

Side effects of medication

Side effects of older schizophrenia drugs

Anticholinergic side effects are more common with the older typical anti-psychotics and include dry mouth, blurred vision, flushing and constipation. These tend to be worse at the start of treatment and often ease off. Drowsiness is also common but may be reduced by reducing the dose. Extrapyramidal side effects (movement disorders) can occur with typical antipsychotics. Chlorpromazine has a tendency to cause skin photosensitivity when exposed to sunlight. Sunscreen must be used if going out in strong sun while taking chlorpromazine.

Side effects of newer schizophrenia drugs

Reduced risk of movement disorders is the main reason atypical antipsychotic drugs frequently are first choice for treatment. Atypical antipsychotics have their own risks; particularly the risk of weight gain and this increases risk of developing diabetes and heart problems (due to raised cholesterol). Longer term blood sugars and cholesterol levels should be monitored regularly. Weight gain appears to be a particular problem with clozapine and olanzapine. Other medication sometimes used to treat schizophrenia include the likes of antidepressants and mood stabilisers (ask in store for longer version of this article which has more detail on these)

What is the outlook (prognosis)?

In most cases there are recurring episodes of symptoms (relapses). Most people live relatively independently with varying amounts of support. Frequency and duration of each relapse can vary. Some people recover completely between relapses. Some people improve between relapses but never quite fully recover. Treatment often prevents relapses, or limits their number and severity.

Outlook is thought to be better if:

• Treatment is started soon after symptoms begin.
• Symptoms develop quickly over several weeks rather than slowly over several months
• The main symptoms are positive symptoms rather than negative symptoms.
• The condition develops in a relatively older person (aged over 25).
• Medication is taken as advised.
• There is good family and social support which reduces anxiety and stress.
• Abuse of illegal drugs or alcohol does not occur.

Newer drugs and better psychological treatments (discussed in more detail in my longer article) mean that prognosis is now better than it was in the past.

Whelehans Pharmacy, 38 Pearse Street, Mullingar. Tel 04493 34591. Eamonn’s full comprehensive article is available in Whelehans on request. Ask staff for a free copy.

Overview

For my detailed article on schizophrenia ask Whelehans staff for a free copy or log on to www.whelehans.ie.

Symptoms

Symptoms include hallucinations (seeing and hearing things), delusions (false ideas), disordered thoughts, and problems with mood, behaviour and motivation. It can cause a loss of touch with reality thus becoming unable to tell what is real and what is not. The cause is not clear. Symptoms can recur or persist long-term, but some people have just one episode of symptoms lasting a few weeks.

Positive and negative symptoms

The symptoms are classed as either positive or negative. Positive symptoms are abnormal mental functions while negative symptoms are a loss of normal mental functions.

Negative symptoms include loss of motivation (loss of interest in social activities and mixing with people, loss of concentration and inability to complete activities you previously had no problem completing), loss of a sense of pleasure, slow movements, lack of facial expression and low or flat mood. The person may neglect appearance and look unkempt. Negative symptoms of schizophrenia are similar to depression symptoms and can be misdiagnosed as depression

Positive symptoms are psychotic behaviours not seen in healthy people; they cause loss of touch with reality and include delusion, hallucinations, disordered thoughts and movement disorders

Incidence and prevalence

Schizophrenia occurs in about 1 in 100 people; this rate is the same for all ethnic groups. It occurs equally in men and women. It most often first develops between the ages of 15 to 25 in men and 25 to 35 in women. First diagnosis of schizophrenia is rare after the age of 45. The cause is not clear. It tends to run in families; 70% of the risk of schizophrenia is thought to be hereditary.

Treatment

People living schizophrenia often do not realise they have a mental illness and may not think they need help because they believe their delusions or hallucinations are real. Antipsychotic drugs are broadly divided into two categories; older typical or newer atypical antipsychotics.

Older typical antipsychotics

Sometimes called first generation antipsychotics; first appeared in the 1950’s. Examples include chlorpromazine (Largactil^®), trifluoperazine (Stelazine^®), haloperidol (Serenace^®), flupentixol (Depixol^® Injection, Fluanxol^® tablets), zuclopenthixol (Clopixol^® Injection), and sulpiride (Dolmatil^®). 30% of patients have a relapse during treatment with first-generation antipsychotic drugs compared with 80% without treatment.

Newer or atypical antipsychotics

Also known as second generation antipsychotics; first prescribed in the 1990’s. Examples are amisulpride (Solian^®), aripiprazole (Abilify^®), clozapine (Clozaril^®), olanzapine (Zyprexa^®), quetiapine (Seroquel^®) and risperidone (Risperdal^®). Atypical antipsychotics are often used first-line for newly diagnosed schizophrenia. This is because they demonstrate good balance between chance of success and the risk of side-effects.

Depot injections of an antipsychotic drug

Non-compliance can be a problem with schizophrenia. An American study showed that 74% of patients with schizophrenia discontinued medication within 18 months without consulting with their doctor leading to relapses. Non-compliance is similar for atypical and typical antipsychotics; therefore depot injections can be a solution where compliance is a problem. A depot injection is a long acting injection which is administered by a doctor or nurse and only needs to be administered typically every few weeks.

To be continued….next week I discuss treatment in more detail

Whelehans Pharmacy, 38 Pearse Street, Mullingar. Tel 04493 34591. Eamonn’s full comprehensive article is available in Whelehans on request. Ask staff for a free copy.

Long term medication options for rheumatoid arthritis

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

This is the final of three articles on rheumatoid arthritis (RA). Disease modifying anti-rheumatic drugs (DMARDs) are core to treatment as they slow down or stop the progression of the condition and prevent joint deformities. They allow people enjoy a normal life. 

Disease-modifying antirheumatic drugs (DMARDs)

DMARDs help ease symptoms and slow the progression of RA. The earlier a DMARD is started, the more effective it is. They must be started by a consultant rheumatologist; therefore, it is important to seek treatment with a rheumatologist early if showing signs of RA.

The most commonly used DMARDs include methotrexate, hydroxychloroquine and sulfasalazine. Methotrexate is often the first choice DMARD for RA. It can be taken on its own or in combination with another DMARD. Side effects of methotrexate can be sickness, diarrhoea, mouth ulcers, hair loss or hair thinning, and rashes on the skin. Regular blood tests to monitor blood count and liver are required as methotrexate can cause serious liver and blood count problems. Most people tolerate methotrexate well and more than 50% of patients take it for at least five years.

Methotrexate improves symptoms by 50-80%, slows the rate of joint destruction and improves function and quality of life. Doses of methotrexate up to 20mg weekly may be needed. Injection form may be considered in severe acute RA, if oral treatment is ineffective or in those unable to tolerate oral methotrexate. It takes 6 to 12 weeks for methotrexate to start working. Methotrexate may be combined with biological treatments. It is very important to emphasise that methotrexate is a weekly dose.

Sulfasalazine has a slow onset of effect (1 - 3 months). Patients may need to discontinue long-term treatment of sulfasalazine due to gastrointestinal complaints.

Hydroxychloroquine takes several weeks to exert its effect. It has been reported to be less effective than the other DMARDs but is well-tolerated; therefore, it may be useful in mild disease or in combination therapy. It can cause eye damage so regular eye checks are needed.

Immunosuppressants

Azathiaprine (Imuran^®) and Ciclosporin (Neoral^®) tend to be reserved for severe RA, when other DMARDs are ineffective or inappropriate. They tend to be last line as they have potential serious side effects, mainly due to their suppression of the immune system. 

Biological treatments

Biological treatments are a newer form of treatment for RA. They include TNF-alpha inhibitors (etanercept , infliximab, adalimumab and certolizumab), rituximab and tocilizumab. Etanercept (Enbrel^®) and adalimumab (Humira^®) are most commonly prescribed biological treatments for RA in Ireland. In general, biological agents are reserved for patients with moderate to severe active RA where conventional DMARDs have failed. They are usually taken in combination with methotrexate or sometimes with another DMARD. They work by stopping particular chemicals in the blood from activating the immune system to attack the lining of joints. They are given by subcutaneous injection. Side effects from biological treatments are usually mild and include skin reactions at the site of injection, infections, nausea, fever and headaches.

Educate yourself about your condition

Whelehans Pharmacy, in conjunction with Arthritis Ireland (Westmeath Branch) host a Rheumatoid Arthritis Information event next week (Wednesday Oct 12^th at 6:45pm) in Greville Arms Hotel Mullingar. Admission is free.

Guest speaker for the evening is Consultant Rheumatologist from Midland Hospital Tullamore, Killian O’Rourke MD MSc FRCP FRCPI. Dr O’Rourke will give first-hand information on RA along with self-help tips including information about surgery and aftercare. He will take questions from attendees.

Chartered physiotherapist Kevin Conneely MISCP of HealthStep Physiotherapy Mullingar will discuss role of physiotherapy in Rheumatoid Arthritis (RA).  The final speaker is pharmacist Eamonn Brady MPSI who will discuss medication.