Hospital utilization rates following antipsychotic dose reductions: implications for tardive dyskinesia

Abstract

BackgroundData are limited on the benefits and risks of dose reduction in managing side effects associated with antipsychotic treatment. As an example, antipsychotic dose reduction has been recommended in the management of tardive dyskinesia (TD), yet the benefits of lowering doses are not well studied. However, stable maintenance treatment is essential to prevent deterioration and relapse in schizophrenia.MethodsA retrospective cohort study was conducted to analyze the healthcare burden of antipsychotic dose reduction in patients with schizophrenia. Medical claims from six US states spanning a six-year period were analyzed for ≥10% or ≥ 30% antipsychotic dose reductions compared with those from patients receiving a stable dose. Outcomes measured were inpatient admissions and emergency room (ER) visits for schizophrenia, all psychiatric disorders, and all causes, and TD claims.ResultsA total of 19,556 patients were identified with ≥10% dose reduction and 15,239 patients with ≥30% dose reduction. Following a ≥ 10% dose reduction, the risk of an all-cause inpatient admission increased (hazard ratio [HR] 1.17; 95% confidence interval [CI] 1.11, 1.23; P < 0.001), and the risk of an all-cause ER visit increased (HR 1.09; 95% CI 1.05, 1.14; P < 0.001) compared with controls. Patients with a ≥ 10% dose reduction had an increased risk of admission or ER visit for schizophrenia (HR 1.27; 95% CI 1.19, 1.36; P < 0.001) and for all psychiatric disorders (HR 1.16; 95% CI 1.10, 1.23; P < 0.001) compared with controls. A dose reduction of ≥30% also led to an increased risk of admission for all causes (HR 1.23; 95% CI 1.17, 1.31; P < 0.001), and for admission or ER visit for schizophrenia (HR 1.31; 95% CI 1.21, 1.41; P < 0.001) or for all psychiatric disorders (HR 1.21; 95% CI 1.14, 1.29; P < 0.001) compared with controls. Dose reductions had no significant effect on claims for TD.ConclusionPatients with antipsychotic dose reductions showed significant increases in both all-cause and mental health–related hospitalizations, suggesting that antipsychotic dose reductions may lead to increased overall healthcare burden in some schizophrenia patients. This highlights the need for alternative strategies for the management of side effects, including TD, in schizophrenia patients that allow for maintaining effective antipsychotic treatment.Electronic supplementary materialThe online version of this article (10.1186/s12888-018-1889-2) contains supplementary material, which is available to authorized users.

Hospital utilization rates following antipsychotic dose reduction in mood disorders: implications for treatment of tardive dyskinesia

“…This study used realworld claims data to compare the risk of both all-cause and mental health-related admissions and ER visits in patients with BD or MDD who had dose reductions with matched controls on stable oral dosages of antipsychotics. The results show that among patients with mood disorders, dose reductions resulted in small but statistically significant increases in inpatient admissions and ER visits, similar to previous findings among patients with schizophrenia [23].…”

“…Moreover, interpretation of the relationship between dose reduction and TD is limited in this study by the shorter follow-up period in cases and the very low frequency of TD claims suggesting a high rate of false negative diagnoses [31]. In fact, the prevalence rate of TD reported in retrospective database studies like ours is significantly less than in prospective clinical trials of mood disorder patients [11,12,23,[32][33][34]. These results clearly indicate that TD is seriously underreported in claims databases [34] and should be documented in a more systematic fashion.…”

“…When side effects emerge during maintenance treatment with antipsychotics, management options include drug maintenance, discontinuation, switching, or dose reduction [5,6,12,[19][20][21][22][23]. For example, in patients with mood disorders in remission, maintenance treatment with antipsychotics may be unnecessary, and discontinuation may be reasonable to facilitate remission of TD or other side effects.…”

“…In patients who require continued antipsychotic maintenance treatment, dose reduction has also been considered as an option once TD occurs. In a previous retrospective cohort study, we demonstrated that antipsychotic dose reductions resulted in significant increases in both all-cause and mental health-related hospitalizations, worsening the overall healthcare burden in schizophrenia patients [ 23 ]. However, there are no data examining the effect of dose reduction on symptoms of TD in mood disorders [ 20 , 24 , 25 ].…”

“…To further address the gap in knowledge on the risks of dose reduction as a recommended treatment intervention for side effects of antipsychotic treatment, including TD, we used the same methodology from the previous study in schizophrenia [ 23 ] to conduct a retrospective matched cohort study to analyze the utilization of hospital-based resources resulting from ≥10% and ≥ 30% reductions in antipsychotic doses for patients with BD or MDD.…”