Skating on thin ice: pragmatic prescribing for medication refractory XXXX .

@entity1 @entity1088 @entity1092 @entity1833 @entity161 @entity716 @entity14867 @entity1091 @entity1037 @entity2812 @entity1089
BACKGROUND: @entity1088 is the treatment of choice for medication refractory @entity716 , but it does not benefit half of those put on it. There are numerous studies of potential post- @entity1088 strategies, but little data to guide the order of such treatment in this common clinical challenge. We describe a naturalistic observational study in 153 @entity1 treated by a specialist @entity716 service to identify optimal pharmacotherapy practice, based on outcomes. METHODS: Medication and clinical data, based on the OPCRIT tool, were examined on admission and discharge from the national @entity716 service. The primary outcome measure was the percentage change in mental state examination symptoms between admission and discharge and the association with medication on discharge. Exploratory analyses evaluated the specificity of individual medication effects on symptom clusters. RESULTS: There were fewer drugs prescribed at discharge relative to admission, suggesting an optimisation of medication, and a doubling of the number of @entity1 treated with @entity1088 . Treatment with @entity1088 on discharge was associated with maximal decrease in symptoms from admission. In the group of @entity1 that did not respond to @entity1088 monotherapy, the most effective drug combinations were @entity1088 augmentation with 1) @entity1092 , 2) @entity1091 , 3) @entity14867 , and 4) @entity1089 . There was no support for a dose-response relationship for any drug combination. CONCLUSIONS: @entity1088 monotherapy is clearly the optimal medication in medication refractory @entity161 and it is possible to maximise its use. In @entity1 unresponsive to @entity1088 monotherapy, augmentation with @entity1092 , @entity1091 , @entity14867 and @entity1089 , in that order, is a reasonable treatment algorithm. Reducing the number of ineffective drugs is possible without a detrimental effect on symptoms. Exploratory data indicated that @entity1088 was beneficial across a range of symptoms domains, whereas @entity1037 was beneficial specifically for @entity1833 and @entity2812 for comorbid affective symptoms.
