Drug Prescription Report 2012: Antipsychotics

I have not yet covered the antipsychotics in my reporting on the drug prescription report, I want to catch this today. This important group of drugs is discussed in the chapter “psychotropic drugs”. As mentioned already in my post from November 9th, 2012, the quality of the chapter suffers greatly from the superficial and unscientific representation of the two authors Lohse and Müller-Oerlinghausen. I will essentially limit this post on the discussion of the numbers rather than discuss the limitations of the chapter again.

Lohse and Müller-Oerlinghausen merge the antipsychotics together into three groups: High-potency neuroleptics, low-potency neuroleptics and atypical neuroleptics. Among the high-potency neuroleptics, they include haloperidol, benperidol, fluphenazine, fluspirilene, thioridazine, perazine, flupentixol, zuclopentixol, pimozide and perphenazine. The group of low-potency neuroleptics contains promethazine, melperone, sulpiride, levomepromazine, pipamperone, chlorprothixene and prothipendyl. The atypical antipsychotics include clozapine, amisulpride, olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone and paliperidone (the depot preparation Xeplion®). I have critically dealt with the problems of this classification at various points. Nevertheless, I use the above-mentioned nomenclature here, because the published figures and tables are based on it.

Prescription of high-potency neuroleptics has decreased in recent years, slowly but steadily. 2002, 100 million DDD had been prescribed, in 2011 this number was 76 million DDD (according to the table, however, there were only 70.3 million DDD, here is a discrepancy between figure and table).

The following amounts of high-potency neuroleptics were prescribed in 2011 (followed by the DDD net cost in €):

High-potency neuroleptics:                          70.3 Mio. DDD         (€ 0.61)

  • Haloperidol:                                                  17.1 Mio. DDD         (€ 0.34 – 0.59)
  • Perazine:                                                      14.4 Mio. DDD         (€ 0.35 – 0.37)
  • Flupentixol:                                                   11.6 Mio. DDD         (€ 1.05 – 1.36)
  • Benperidol:                                                     9.4 Mio. DDD         (€ 0.22)
  • Fluphenazine:                                                 8.2 Mio. DDD         (€ 0.34 – 0.94)
  • Zuclopethixol:                                                 5.2 Mio. DDD         (€ 0.91)
  • Fluspirilene:                                                    2.2 Mio. DDD         (€ 1.36 – 1.61)
  • Thioridazine:                                                   1.1 Mio. DDD         (€ 0.87 – 1.63)
  • Pimozide:                                                       0.9 Mio. DDD         (€ 0.67)
  • Perphenazine:                                                0.2 Mio. DDD         (€ 1.95)

In this group the prescription of haloperidol increased most significantly in the previous year (+ 4.2%). The volume of prescriptions of thioridazine decreased significantly (- 10.1%), which is welcome, because the substance is supposed to be obsolete because of the sometimes considerable prolongation of the QTc interval occurring with this compound.

The prescription of atypical neuroleptics (better: second-generation antipsychotics) has steadily increased in recent years, in 2005 more atypical than high-potency neuroleptics (first-generation antipsychotics) were prescribed for the first time. In 2002, 60 million DDD were prescribed, 2011 already 161 million DDD (according to table 150.8 million DDD). Thus, in 2011 more than twice as many atypical neuroleptics than high-potency neuroleptics were prescribed in Germany. Considering, however, that the so-called low-potency neuroleptics all belong to the first generation, the number of prescriptions are still roughly equal.

In 2011, atypical neuroleptics were prescribed as follows:

Atypical neuroleptics:                              150.8 Mio. DDD       (€ 5.64)

  • Quetiapine:                                                       44.4 Mio. DDD       (€ 6.92)
  • Risperidone:                                                     35.0 Mio. DDD       (€ 0.67 – 12.78)
  • Olanzapine:                                                      30.6 Mio. DDD       (€ 7.02)
  • Clozapine:                                                        14.3 Mio. DDD       (€ 1.34 – 1.93)
  • Aripiprazole:                                                     11.3 Mio. DDD       (€ 9.59)
  • Amisulpride:                                                       8.9 Mio. DDD       (€ 1.11 – 1.94)
  • Ziprasidone:                                                       5.4 Mio. DDD       (€ 6.07)
  • Paliperidone:                                                      0.9 Mio. DDD       (€ 14.42)

Thus, although amisulpride and risperidone (and since the end of 2011 also olanzapine) are available generically, quetiapine is the most commonly prescribed antipsychotic medication in Germany. The presciptions of this compound increased 2011 as compared to 2010 by 12%. This is certainly also a result of the fact that the substance is now also  given (and approved) in mood disorders. Treatment with risperidone is now possible at  daily costs of less than € 1, yet the original drug, which was 20 times more expensive, was still relatively commonly prescribed (7.8 million DDD). Prescription of aripiprazole increased from 2010 to 2011 by 17%.

Prescription of low-potency neuroleptics increased slightly over the previous year by about 2%. Almost half of all prescriptions were attributable to the predominantly antihistaminic promethazine:

Low-potency neuroleptics:                                     73.2 Mio. DDD       (€ 1.09)

  • Promethazine:                                                   33.2 Mio. DDD       (€ 0.39 – 0.89)
  • Melperone:                                                        11.9 Mio. DDD       (€ 1.64 – 2.81)
  • Pipamperone:                                                   10.6 Mio. DDD       (€ 1.70 – 2.45)
  • Chlorprothixene:                                                 6.5 Mio. DDD       (€ 0.68 – 0.94)
  • Prothipendyl:                                                      3.9 Mio. DDD       (€ 1.20)
  • Sulpiride:                                                            3.6 Mio. DDD       (€ 1.79 – 2.13)
  • Levomepromazine:                                             3.5 Mio. DDD       (€ 0.89 – 2.06)

The two  butyrophenones melperone and pipamperone, which are commonly used in the elderly because of their low anticholinergic effects, are being prescribed quite often, their prescriptions further increased over the previous year. Their relatively high prices are somewhat surprising, given that they are generically available.

This post is also available in: German

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