Expert consensus-based medication-use evaluation criteria for atypical antipsychotic drugs

Medication-use criteria for the appropriate use of atypical antipsychotics were developed through a national consensus process utilizing an expert panel. A written survey was prepared which asked for opinions about options for psychopharmacologic interventions with seven antipsychotic drugs or categories (clozapine, olanzapine, quetiapine, risperidone, ziprasidone, long-acting intramuscular decanoate ester preparations of conventional antipsychotics, and oral conventional antipsychotics) in 19 specific clinical situations. The survey was sent to 50 psychiatrists and psychiatric pharmacist specialists, 42 (84%) of whom completed the survey. The survey was formatted as a grid with rows listing various clinical situations and columns itemizing the various antipsychotic medications relevant to the situations. Responses were scored using a 9-point scale for rating the level of medical review required for any given decision. Consensus on each option was defined as a nonrandom distribution of scores by a chi-square goodness-of-fit test. Consensus was reached for 1179 of the 1230 items reviewed. Use of clozapine as a first-line therapy warranted prospective or mandated review for all diagnoses. Use of nonclozapine atypical agents for schizophrenia and schizoaffective and delusional disorders was judged to be the standard of care. Oral conventional antipsychotic agents were not considered the standard of care for any indication. Combination antipsychotic treatment always warranted at least concurrent review. Continued concerns about the use of ziprasidone and its cardiac effects were apparent. This study demonstrated the utility of a consensus-based process in addressing issues and practices not adequately addressed in the scientific literature.