On October 31, 2019, the Swiss Society for Drug Safety in Psychiatry (SGAMSP) will meet at the Kilchberg Sanatorium for its annual meeting. The event will be moderated by Past President Dr. Alice Walder and Prof. Dr. Katja Cattapan. What are the core issues? We asked the speakers.
Autonomy and medication
Prof. Hoff, one of the topics of the conference is autonomy in psychopharmacotherapy. Does the administration of psychotropic drugs constitute a limitation of autonomy?
Prof. Hoff: Any kind of psychiatric treatment is embedded in the therapeutic relationship. Some patients express concern about loss of autonomy simply by taking psychotropic drugs. In this situation, a sustainable therapeutic relationship is crucial.
Can you give an example of an ethical challenge?
Prof. Hoff: An underestimated topic is “soft coercion”: How do I react when a patient wants to discontinue his clearly indicated neuroleptic therapy without a convincing reason? How do I find the person-centered balance between the patient’s autonomy and their demand for optimal treatment?
Fewer relapses due to depot medication
Prof. Hasler, doesn’t a depot medication with an effect of two, four weeks or even three months mean a strong restriction of the patient’s autonomy?
Prof. Hasler: His autonomy in terms of daily dosage is actually reduced. On the other hand, due to the decrease in relapses, his autonomy in life increases. Depot preparations also reduce the likelihood of coercive measures.
Are there any new developments in this area?
Prof. Hasler: With Abilify Maintena® and Trevicta® we have two new important options in Switzerland. Abilify Maintena® is characterized by a favorable side effect profile, e.g.
little weight gain and metabolic
Disturbances. With Trevicta® , the three-month duration of action is a major advantage for a number of patients.
Women are generally overdosed
Prof. Greil, you will report on the AMSP project on gender differences. What’s new?
Prof. Greil: The U.S. Food and Drug Administration (FDA) has set a maximum dose of 5 mg for the sleeping pill zolpidem for women. This is because women, at the 10 mg dosage approved for men, are not yet sufficiently fit to drive the next morning because of the drug’s slower breakdown. Our evaluations show that such sex differences in pharmacokinetics are poorly observed in our setting. The standard dosage for men and women, which is the same here, often means an overdose for women. This could be an important reason for the increased rate of side effects in women.
Alternatives to coercive measures would be
Dr. Bridler, you are going to talk about prescribing psychotropic drugs against one’s will. Are there efforts to limit this coercive measure in residential treatment?
Dr. Bridler: The entry into force of the new adult protection law in 2013 has primarily brought about a legalization of coercive measures in Switzerland, but not a reduction. There is psychiatric research on reducing inpatient restraints through living wills, mobile teams, soteria homes, or outpatient restraints. However, as long as society approves coercive measures, including the prescription of medication against the will, and enshrines them in law, alternatives will have a hard time. This is because they are more expensive and the back door to coercive measures is open.
Wide use of ABCB1 genotyping would be premature
Dr. Jetter, are there already approaches to personalized medicine or precision medicine in psychopharmaceutical therapy as well?
PD Dr. Jetter: For the treatment with carbamazepine, it is already stated in the professional information that, for the risk assessment of severe adverse skin reactions before the start of therapy, a
genetic test for the presence of the allele HLA-A*3101 should be performed. This applies to people of European, Japanese, South Indian and Arab origin. For East Asians, testing for a different HLA allele is mandatory. Genotyping may also be useful prior to treatment with atomoxetine (Strattera®). In case of a gene defect (“poor metabolizer” of CYP2D6), the drug is degraded very slowly. This leads to a greatly increased risk of adverse effects, including toxic reactions. Therefore, if a gene variant is detected that results in CYP2D6 failure, a very low initial dose and slow titration should be considered.
When pharmacogenetic testing is ordered, a positive opinion from a clinical pharmacologist is required. Do you recommend the widespread use of ABCB1 genotyping?
PD Dr. Jetter: So far, only a quite small benefit has been shown once well in a very selected group of patients. Therefore
unfortunately, the studies to date are not sufficient to prove a clinical benefit of ABCB1 genotyping in the drug therapy of depression. At this point in time, therefore, the general introduction of
of ABCB1 genotyping in clinical practice is premature.
The interview was conducted by the editorial team.
Event Notice:
Annual Meeting SGAMSP 2019
Thursday, 10/31/2019, 1:30-5:00 p.m.
Kilchberg Sanatorium, Alte Landstrasse 70-84, 8802 Kilchberg
Registration by e-mail: info@sgamsp.ch
Registration deadline: 10.10.2019
