In episode 135, Mike and James and Adil finally get to the end of their antipsychotic tetralogy as they tackle the especially difficult issue of the use of antipsychotics in the elderly. The problem is non-pharmacological treatments do very little, and one is left with having to decide whether or not to use drugs. We discuss the evidence of effectiveness (or lack thereof) of these drugs and the very real potential for harm. At the end, Adil makes both Mike and James agitated and he sedates them with a high dose of a very fine cognac. 

Show notes

1) Non-pharmacological interventions

Aging Ment Health 2009;13:512-20

2) Use of antipsychotics for psychosis of dementia

Int J Geriatr Psychiatry 2007;22:475-84

Psychother Psychosom 2007;76:213-8

Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003476. 

3) Adverse effects of the antipsychotics

JAMA 2005;294:1934-43

NEJM 2005;353:2335-41

Ann Intern Med 2007;146:775-86

4) DART-AD study – effect of stopping antipsychotics

Lancet Neurol 2009;8:151–7

PLoS Med 5(4):e76.doi:10.1371/journal.pmed.0050076

5) Tools for practice

What are the Risks and Benefits of Stopping Antipsychotics in the Elderly?

In episode 134, we get into the nitty gritty of choosing a second drug for schizophrenia if the first one doesn’t work or is not tolerated. In general, it appears there is some evidence to favour clozapine over other agents but the difference isn’t great and as with virtually all of medicine one has to intermingle the available evidence with a good dose of art to make a beautiful therapeutic picture.   

Show notes

1) CATIE

N Engl J Med 2005;353:1209–23

2) CUtLASS 1

Arch Gen Psychiatry 2006;63:1079–87

3) A meta-analysis of the efficacy of second-generation antipsychotics 

Arch Gen Psychiatry 2003;60:553-64

2) Clozapine versus other atypical antipsychotics for schizophrenia

Cochrane library

3)Clozapine versus typical neuroleptic medication for schizophrenia

Cochrane library

4) CATIE – clozapine versus other agents who do not respond to prior atypical antipsychotic treatment 

Am J Psychiatry 2006;163:600–10

In episode 133, Mike and James again welcome Adil Virani to help us along with our antipsychotic drug discussion. We discuss the differences between the first and second generation antipsychotics, how to start, and when to consider a depot preparation. At the end of the podcast James realises that he has basically been hearing voices for the entire podcast but was reassured to find out the voices were actually Mike and Adil’s and that in general, they were telling the truth. 

Show notes

1) CATIE

N Engl J Med 2005;353:1209–23

2) CUtLASS 1

Arch Gen Psychiatry 2006;63:1079–87

Schizophr Bull 2006;32:715–23

3) Haloperiodol vs risperidone

N Engl J Med 2002;346:16-22

In episode 132, Mike and James bring back their good friend and psych colleague Adil Virani, to help out in thinking about the use of antipsychotics. In part 1, we talk about schizophrenia in general and start to get into a discussion of the use of antipsychotics for this condition and how to decide what drugs to choose. However, at the end our thought process becomes a bit scattered and we decide to leave the discussion about the specific drugs to the next podcast.

Show notes

None

In episode 131, Mike and James have invited Denise Campbell-Scherer into the podcast world to help us discuss the issue of multimorbidity when it comes to guidelines and chronic medical conditions. We talk about how to think about this issue when it comes to research and practice and we very quickly realise it is tricky and it demands that clinicians need to realise that guidelines are system-based and not patient specific focussed. At the end we decide that we need to take care of patients and not disease states.

Show notes

1) Multimorbidity: a challenge for evidence-based medicine

Evidence-Based Medicine 2010;15:165-6

2) The quality of life and time associated with treating chronic conditions

JAMA 2005;294:716-724

In episode 130, Mike and James run directly into the face of the evidence around exercise and really sweat out the weightiness of the results. We actively find out that it’s primarily all about quality of life, and that Mike bikes and James rollerblades to keep themselves as close to perfect physical specimens as possible. At the end we find out they also both take medications for delusions of grandeur.

Show notes

1) Activity-related benefits

Cochrane 2002;(4):CD003404

J Gerontol A Biol Sci Med Sci 2008;63:997-1004

J Sports Med Phys Fitness 2007 Dec;47:462-7

Cochrane 2008 Oct 8;(4):CD004366

Cochrane 2008 Oct 8;(4):CD004376

Arch Intern Med 2007;167:2453-60

JAMA 2003;289:2379-86

NEJM 2002; 347 (10): 716-25

JAMA 1995; 273 (14): 1093-8

Circulation 2008;117: 614-22

PLOS 2008; 5(1): e12

2) Quality of life and dose response

Arch Intern Med 2009;169:269-78

Circulation 2010;122:743-752

Br J Sports Med 2008;42:238–43

NEJM 1999;341:650-8

Eur J Epidemiol 2009;24:181–192

3) Exercise for overall benefit not on surrogate markers

J Appl Physiol 2008;105:766–8

4) RCT evidence on exercise

Circulation 2004;109:1371-8

Am J Med 2004;116:682–92

5) Motivating patients

JAMA 2007;298:2296-304

Res Q Exerc Sport 2009;80:648-55

Int J Behav Nutr Phys Act 2008;5:44

Diabetes Care 2009;32:1404-10

Arch Intern Med 2007;167:2453-60

JAMA 1995;273:1093-8

Ann Fam Med 2008;6:69-77

Am J Public Health 1998;88:288-91

In episode 129, we get back to giving our listeners PREMIUM content and we end up spending the entire time talking about drugs that, in theory, make you pee – and you wonder why we call this a PREMIUM podcast. We discuss a synopsis of an old drug hydrochlorothiazide and then we discuss the most recent clinical trial of the new aldosterone antagonist eplerenone. The podcast comes to an abrupt end when, because of either the topic or the coffee, both Mike and James have to leave to leave to attend to more important matters.

Show notes

1) Hydrochlorothiazide – what is the evidence for its use?

J Am Coll Cardiol 2011;57:590-600

2) Eplerenone – EMPHASIS-HF study

N Engl J Med 2011;364:11-21

3) Aldosterone antagonist systematic review

Euro H J 2009;30,469–77

In episode 128, James and Mike finally get to the last of the listener questions We discuss codeine and cough, Vapor Rub; we talk about the PREMIUM podcast, otitis media and antibiotics, atrial fibrillation and low dose statins. We then both collapse from exhaustion yet promise to get back to making premium podcasts as soon as possible.

Show notes

Codeine and cough

Can Fam Phys 2010;56:1293-4

Cochrane Library

In episode 127, Mike and James attempt to answer questions about topical NSAIDs, bleeds on NSAIDs and SSRIs, Strep throat, statins in the UK, and NSAIDs and CVD risk. They smish and smash all the available data into partly coherent answers, yet give definitive and dogmatic answers with the conviction of a dog with a bone or a cardiologist with a statin.

Show notes

1) SSRIs and bleeds

Alimentary Pharmacology & Therapeutics 2008;27:31-40

Arch Intern Med 2003;163:59-64

2) Dipstick urinalysis

In women with dysuria, frequency, and no vaginal discharge the probability of UTI is 96%

JAMA 2002;287:2701-10

In episode 126, James and Mike discuss how to do a drugectomy and why one needs to consider evidence, efficacy, side effects, cost, patient preference and that as clinicians we need to do many “n of 1” trials. We then discuss the concerns around dabigatran and what to do about bleeding on this agent and why the FDA made the 150 mg dose the chosen one. We also provide commentary on how long we need to give antibiotics and if you really need to take them until they are “all gone”. At the end we advise listeners to only listen to the podcasts until they feel better and then stop before they get any side effects like annoyance or frustration.

Show notes

1) Dabigatran and the FDA – why 150 mg?

NEJM 2011;364:1788-90