The lesser of two evils: a qualitative study of quetiapine prescribing by family physicians

Abstract

Global antipsychotic sales in 2010 were US$25.4 billion; of these, Seroquel (quetiapine) was the fifth highest selling pharmaceutical worldwide, costing an estimated US$6.8 billion. 4 In Canada, prescriptions for quetiapine rose by 300% between 2005 and 2012. Using the IMS Brogan Canadian CompuScript databases to identify prescribing data, researchers found that 50% of filled antipsychotic prescriptions in Canada were for quetiapine, and most came from family physicians.2 Although quetiapine is licensed for the treatment of schizophrenia and bipolar disorder and as an adjunctive to antidepressants in moderate to severe depression, much prescribing of quetiapine is offlabel.2,5 Off-label prescribing of antipsychotics has been studied extensively, including a meta-analysis of 170 studies. 6Leslie and colleagues 7 examined prescribing data from the US Department of Veteran Affairs and found that 60.2% of the 279 778 patients who received a prescription for an antipsychotic in 2007 had no indication for its licensed use; of these, 43% were prescribed quetiapine. More recently, researchers in the United Kingdom examined prescribing data using The Health Improvement Network, a primary care database of almost 10 million patients. 5 They found that only 36% (n = 4824) of those prescribed quetiapine had a serious mental illness recorded. Insomnia, anxiety and behavioural disturbance in elderly people and children are common reasons for off-label use. 3,6,8 Evidence of benefit for these indications is disputed. 6,9,10 Adverse metabolic, neurologic and cardiovascular effects 9,11 pose a significant risk of harm.11,12 Maglione and colleagues 6 calculated a number needed to harm of 8 (odds ratio 5.16, 95% confidence interval 2.93-9.51) for neurologic adverse effects in patients with dementia and of 16 (odds ratio 2.72, 95% confidence interval 2.07-3.56) for weight gain and increased appetite in other conditions. Background: Quetiapine is an antipsychotic that is widely prescribed off-label by family physicians despite evidence that safer alternatives exist. The aim of this research was to explore, in-depth, family physicians' reasons for this behaviour.

Who prescribes quetiapine in Denmark?

“…As quetiapine has considerable anxiolytic and hypnotic properties, especially in low doses, it might be considered a viable treatment option for these patients. A Canadian study 6 has explored physicians’ reasons for use of quetiapine and found complex psycho‐social needs, the positive attitude of colleagues towards quetiapine, and the apparent absence of adverse events with low doses, to be potential explanations for off‐label use of quetiapine. Additionally, low‐dose use of quetiapine has not been associated with increased risk of diabetes 15 or increased risk of dependency, although reports accumulate on extramedical use of quetiapine 16 .…”

“…4,5 Increased awareness to reduce the use of benzodiazepines due to their potential for dependency and adverse events, might have offset a corresponding increase in the off-label use of quetiapine (and other antipsychotics). 6 However, the use of quetiapine is problematic as it has been associated with adverse events, including QT-prolongation, somnolence, weight gain and metabolic dysregulation. 7 A prior study on off-label use of antipsychotics in Denmark indicated that a substantial proportion of the off-label use might be driven by prescription in general practice.…”

Prescription Dose Analysis of Quetiapine in the Elderly and Insomnia

“…This result can be evaluated as meaning that quetiapine is more preferred for off-label use when considering the safety aspect of antipsychotics in elderly patients. Clinically, it has been reported that a large number of doctors are using low-dose quetiapine instead of benzodiazepines to treat insomnia, considering the side effects of benzodiazepines [24]. However, El-Saifi et al [25] found that the use of quetiapine in the elderly is associated with a higher risk of falls and an increased mortality rate in the Parkinson's population.…”

“…Quetiapine is generally widely prescribed in patients with other psychiatric comorbidities [24]. In this study, quetiapine is also used in sleep disorders with other comorbidities such as depressive disorder, anxiety disorder, and psychosis.…”

Quetiapine for primary insomnia: Consider the risks

“…In 2018, Kelly et al 45 investigated outpatient prescribing of quetiapine among family physicians. Quetiapine was generally reserved for patients who had not responded to other therapies or had psychiatric comorbidities or diffi cult social backgrounds.…”