Pharmacogenetics of adverse events in schizophrenia treatment: comparison study of ziprasidone, olanzapine and perazine

The primary aim of the present study was to assess the possible associations between dopaminergic, serotonergic, and glutamatergic system-related genes and adverse events after antipsychotic treatment in paranoid schizophrenia patients. The second aim of the study was to compare the intensity of these symptoms between atypical (ziprasidone and olanzapine) and typical (perazine) antipsychotic drugs. One-hundred and ninety-one Polish patients suffering from paranoid schizophrenia were genotyped for polymorphisms of DRD2, DAT1, COMT, MAOA, SERT, 5HT2A, and GRIK3. The patients were randomized to treatment with perazine, olanzapine or ziprasidone monotherapy for 3 months. The intensity of side effects (changes in body weights and extrapyramidal symptoms (EPS)) was measured at baseline and after 12 weeks of antipsychotic treatment. After 3 months of therapy, the weight increase was the greatest in the group treated with olanzapine and the least in the group treated with ziprasidone. None of the examined gene polymorphisms was associated with the body weight changes. Perazine treatment was associated with the significantly highest intensity of EPS. None of the examined polymorphisms was associated with the changes in extrapyramidal adverse events after antipsychotic treatment. The selected polymorphisms are not primarily involved in changes in body weights and EPS related to antipsychotic treatment in paranoid schizophrenia patients.

Perazine for schizophrenia

BACKGROUND

Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia and is reputed to have a low level of extrapyramidal adverse effects. As far as we are aware, its use is limited to Germany, Poland, the former Yugoslavia and the Netherlands.

OBJECTIVES

To examine the effects of perazine for those with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medications.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register, which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile. We searched the references of all included studies for further trials. We contacted pharmaceutical companies and authors of trials. We updated this search on 16th July 2012.

SELECTION CRITERIA

We selected all randomised controlled trials that compared perazine with other treatments for people with schizophrenia or schizophrenia-like psychoses, or both.

DATA COLLECTION AND ANALYSIS

The review authors (SL, BH, BHe) independently inspected the citations and where possible abstracts and ordered papers for re-inspection and quality assessment. We independently extracted data. We calculated the risk ratio (RR) and 95% confidence interval (CI) using a random-effects model. For continuous data, we calculated mean differences (MD). We inspected all data for heterogeneity, assessed trials for risk of bias and created summary of findings tables using GRADE.

MAIN RESULTS

The review now includes seven trials with a total of 479 participants. In only one trial, with 95 participants, perazine appeared superior to 'active placebo' (trimipramine) at five weeks for the outcome of 'no important global improvement' (n = 95, RR 0.43 CI 0.2 to 0.8, low quality evidence), but there was no statistically significant difference in most measures of mental state. Perazine did not induce more general adverse events than placebo but more participants received at least one dose of antiparkinson medication (n = 95, RR 4.50 CI 1.0 to 19.5, very low quality evidence).Six small trials comparing perazine with other antipsychotics, including 384 participants in total, were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible on most occasions. In the six studies, a similar number of participants receiving perazine or comparator antipsychotics (amisulpride, haloperidol, olanzapine, ziprasidone, zotepine) left the studies early (n = 384, RR 0.97 CI 0.68 to 1.38, low quality evidence). The results on efficacy could not be meta-analysed because the authors presented their results in very different ways. No obvious differences in adverse events between perazine and other antipsychotics could be derived from the limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a way that was suitable for use in meta-analysis, but three small comparisons with the second-generation antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n = 111, RR 0.31 CI 0.1 to 1.1), dyskinesia (n = 111, RR 0.47 CI 0.1 to 3.5), parkinsonism (n = 81, RR 1.21 CI 0.5 2.8) or tremor (n = 40, RR 0.80 CI 0.3 to 2.6) with perazine.

AUTHORS' CONCLUSIONS

The number, size and reporting of randomised controlled perazine trials are insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics but this is based on small comparisons. This should be clarified in larger, well-designed trials.

[The influence of antipsychotic therapy on the cognitive functions of schizophrenic patients]

AIM

The aim of the present study was twofold: 1. to compare the efficacy of three antipsychotics (ziprasidone, olanzapine and perazine) in schizophrenia 2. to compare the improvement in cognitive functioning between groups treated with the three different neuroleptics.

METHOD

A total of 58 Caucasian patients diagnosed with paranoid schizophrenia were recruited into the study group. We used the Polish version of the CIDI (Composite International Diagnostic Interview) to obtain ICD-10 diagnoses. The intensity of psychopathological symptoms was examined using the PANSS. The patients were randomly assigned to treatment with perazine, olanzapine or ziprasidone administered as monotherapy for 3 months. The treatment efficacy was measured as a change in the PANSS (Positive and Negative Syndrome Scale) total score from baseline (T0) to 3 months (T1). The WCST (The Wisconsin Card Sorting Test) was used to measure working memory and executive functions in the evaluated patients. Wilcoxon's and Kruskal-Wallis tests were applied to compare changes in the PANSS scores between the treatment groups. To analyze the cognitive functions, Kruskal-Wallis test for the WCST parameters was used.

RESULTS

The three antipsychotics similarly reduced the total PANSS score. The WCST parameters in the 3 groups of examined patients using the Kruskal-Wallis test revealed some differences between the three administered antipsychotics.

CONCLUSIONS

Results suggest that the short-term efficacy of the atypical (olanzapine, ziprasidone) and typical (perazine) antipsychotic drugs did not differ. Based on the analysis, a conclusion can be drawn that the three neuroleptics provided similar improvements in cognitive functioning.

[Physicians' opinion on the use of perazine in the treatment of mental disorders--results of the Delphi consensus study]

AIM

Currently, the use of first generation antipsychotics (FGA) is strongly limited. On the other hand, treatment with second generation antipsychotics (SGA) can not be applied in every patient. Therefore, there is an urgent necessity to obtain information about the knowledge and experience of clinicians with regard to safety and efficacy of pernazine, which represents the most widely used FGA in Poland. Due to a striking scarcity of studies on pernazine, authors designed and performed the study, which should provide physicians knowledge arising from daily practice of clinicians included in this study.

METHODS

Analysis was performed basing on 142 opinions of 26 physicians who were experienced in the treatment with pernazine. The Delphi method, which relies on concluding from expert opinions was adopted in this study. A three-round Delphi was used in order to yield final conclusions.

RESULTS

According to clinicians, pernazine is one of the most cost-effective and well-tolerated FGA. Furthermore, its different profiles of action (anxiolytic and sedative) enable to use pernazine in various indications, as well as in polypharmacotherapy. Referring to a long-term experience, clinicians emphasised the efficacy of pernazine and a high compliance with medication.

CONCLUSIONS

Psychiatric treatment should be individualised taking into account not only clinical indices but also patient's preferences and expectations. According to clinicians pernazine is a safe and versatile medication for schizophrenia or other mental disorders and serves as the alternative for SGA.

[Perazine in the treatment of psychotic disorders--research review]

The author reviewed the relatively poor literature on the topic and its key clinical trial reports on perazine, a classical antipsychotic most frequently prescribed in Poland for psychoses, especially for schizophrenia. Based mainly on the Leucht and Hartung's metaanalysis as well as on other authors' trials with broader context of typical and atypical neuroleptics comparisons, it could be concluded that the perazine bearing balanced profile of psychotropic action (antipsychotic, anti-autistic and sedative) has also some atypical features which explain its broad applications in clinical practice. Not without a meaning are also a few dozen-fold lower costs of treatment, which are even more meaningful when costs of necessary laboratory tests required for monitoring atypical antipsychotics use are taken into consideration.

The role of CYP2D6 and TaqI A polymorphisms in malignant neuroleptic syndrome: two case reports with three episodes

Malignant neuroleptic syndrome (MNS) is a serious and potentially fatal side-effect of neuroleptic treatment. Beside antipsychotic drugs, other psychotropic drugs such as antidepressants and lithium carbonate can cause this life threatening side-effect. Underlying mechanism of this side-effect is still unknown and debated. So far some risk factors have been identified, with clinical observations and recent pharmacogenetic research suggesting (with inconsistent findings) correlation between genetic mechanisms and predisposition to MNS. Polymorphisms of CYP2D6 enzyme through which most psychotropic drugs are metabolized and TaqIA DRD2 which is target for antipsychotic drugs could be the link between pharmacogenetic factors and potential for development of MNS. In this paper we present two case reports with clinical presentation of three consecutive MNS. One patient developed MNS while he was taking combination of drugs: first time haloperidol, promazine and fluphenazine, second time fluphenazine and perazine and third time clozapine, promazine and valproic acid consecutively. The other patient developed MNS while taking following combination of drugs: first time haloperidol and lithium carbonate, second time risperidone and third time clozapine consecutively. Pharmacogenetic analysis for CYP2D6 and TaqI A DRD2 polymorphisms for both patients was done. Genotypisation of CYP2D6*1*3*4*5*6 in both patients showed no evidence of poor metabolizer phenotype. On the other hand, first patient was heterozygous for CYP2D6*4 (genotype *1/*4). CYP2D6 polymorphisms could have clinical significance because may lead to toxicity and unwanted side-effects in standard usual antipsychotic dose ranges. Analysis Taql A DRD2 polymorphism for first patient showed that he is heterozygous for A1 allele (genotype A1A2) which is commonly associated with predisposition to MNS. According to our literature three consecutive MNS are rarely described, and incidence of MNS generally is too low to perform clinical research. Many patophysiological mechanisms may probably underlie this complex and potentially fatal syndrome, still unknown etiology. But, genetic mechanisms could be significant. Further pharmacogenetic research, findings and analysis in patients who develop single or repeated MNS are strongly recommended. In long term, pharmacogenetic analysis, implemented in daily clinical practice, could help in prevention of this extremely serious side-effect.

Perazine and carbamazepine in comparison to olanzapine in schizophrenia

Atypical antipsychotics like olanzapine are more efficacious in treating negative symptoms and have less side effects. Nevertheless, important adverse effects of olanzapine are, for example, weight gain and hyperglycemia. Perazine in combination with carbamazepine has shown satisfying results in several single-schizophrenia patients, leading to the hypothesis of being equal or even superior to atypical antipsychotic monotherapy. The aim of the present study was to survey the hypothesis that perazine in combination with carbamazepine have an outcome and risk of side effects comparable to olanzapine. Eleven patients with DSM-IV schizophrenia received 14.0 +/- 5.0 mg/day olanzapine and 12 patients received 360.0 +/- 196.0 mg/day perazine in combination with 404.0 +/- 229.0 mg/day carbamazepine. Symptoms and neuropsychological state were assessed 3 times (days 0, 7, 21) using the Positive and Negative Syndrome Scale and the Brief Psychiatric Rating Scale. The neuropsychological state was assessed by the following neuropsychological tests: Benton, d2, ZVT, VLMT and MWT-B. Data were analyzed of variance for multiple dependent variables and repeated-measures multivariate analysis of variance. Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale scores showed superior improvement in the group receiving olanzapine. Olanzapine offers a more favorable response in positive symptoms than does perazine in combination with carbamazepine. The effect on negative symptoms is favorable in both forms of therapy and no significant differences between the groups could be determined. In both groups, treatment was associated with improved performance in cognitive tests; however, no differences were determined in the effects of the drugs. Results suggest that olanzapine offers a better response in positive symptoms than perazine in combination with carbamazepine.

Perazine for schizophrenia

BACKGROUND

Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia and is reputed to have a low level of extrapyramidal adverse effects. As far as we are aware, its use is limited to Germany, Poland, the former Yugoslavia and the Netherlands.

OBJECTIVES

To examine the effects of perazine for those with schizophrenia, and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile (last update of the review March 2005). We searched references of all included studies for further trials. We contacted pharmaceutical companies and authors of trials.

SELECTION CRITERIA

We selected all randomised controlled trials that compared perazine with other treatments for people with schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We independently (SL, BH) inspected citations and where possible abstracts and ordered papers for re-inspection and quality assessment. We independently extracted data. We excluded data if loss to follow up was greater than 50%. For homogeneous dichotomous data we calculated the Relative Risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). We inspected all data for heterogeneity.

MAIN RESULTS

We included six trials with a total of 288 participants. In only one trial with 95 participants, perazine appeared superior to 'active placebo' (trimipramine) at five weeks for the outcome of 'no important global improvement' (n=95, RR 0.43 CI 0.2 to 0.8, NNT 4 CI 2 to 13), but there was no statistically significant difference in most measures of mental state. Perazine did not induce more general adverse events than placebo, but more participants received at least one dose of antiparkinson medication (n=95, RR 4.50 CI 1.0 to 19.5, NNH 6 CI 4 to 33). Five small trials comparing perazine with other antipsychotics, including in total only 193 participants, were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible in most occasions. A similar number of participants receiving perazine or comparator antipsychotics left the studies early (n=193, RR 0.85, CI 0.5 to 1.4). The results on efficacy were controversial and need further assessment by randomised controlled trials. No obvious differences in adverse events between perazine and other antipsychotics could be derived from the limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a suitable way for use in meta-analysis, but three small comparisons with the atypical antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n=111, RR 0.31 CI 0.1 to 1.1), dyskinesia (n=111, RR 0.47 CI 0.1 to 3.5), parkinsonism (n=81, RR 1.21 CI 0.5 2.8) or tremor (n=40, RR 0.80 CI 0.3 to 2.6) with perazine.

AUTHORS' CONCLUSIONS

The number, size and reporting of randomised controlled perazine trials is insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics, and this should be clarified in larger, well-designed trials.

Automated analysis of quetiapine and other antipsychotic drugs in human blood by high performance-liquid chromatography with column-switching and spectrophotometric detection

An automated HPLC method with column switching is described for the determination of quetiapine, clozapine, perazine, olanzapine and metabolites in blood serum. After clean-up on silica C8 material (20 microm particle size) drugs were separated on ODS Hypersil C18 material (5 microm; column size 250 mm x 4.6 mm i.d.) within 25 min and quantified by ultraviolet (UV) detection at 254 nm. The limit of quantification ranged between 10 and 50 ng/ml. At therapeutic concentrations of the drugs, the inter-assay reproducibility was below 10%. Analyses of drug concentrations in serum of 75-295 patients treated with therapeutic doses of the antipsychotic drugs revealed mean+/-S.D. steady state concentrations of 139+/-136 ng/ml for quetiapine, 328+/-195 ng/ml for clozapine, 48+/-27 ng/ml for olanzapine and 71+/-52 ng/ml for perazine. The method was thus suitable for routine therapeutic drug monitoring and may be extended to other drugs.

Acute psychosis with a mediastinal carcinoma metastasis

BACKGROUND

Reversible schizophrenia-like syndromes have been reported to occur with small-cell carcinoma of the lung, thymoma, and hematological disorders.

CASE REPORT

A 56-year-old man was admitted due to an acute psychosis characterized by delusions, agitation, and aggressive outbursts. His medical and psychiatric history was unremarkable. On treatment with olanzapine, valproic acid, and perazine there was only moderate improvement. Extensive checkup revealed an isolated mediastinal metastasis of an undifferentiated carcinoma. A primary tumor was not found. After removal of the metastasis, the psychosis remitted rapidly and completely, and the patient remained well on follow-up.

CONCLUSIONS

Paraneoplastic syndromes may clinically present as acute psychoses and, in late-onset schizophreniform disorders with an atypical presentation, performing a tumor search should always be considered.

Antipsychotic efficacy of the antidepressant trimipramine: a randomized, double-blind comparison with the phenothiazine perazine

BACKGROUND

The tricyclic antidepressant trimipramine exhibits several features (e. g., dopaminergic effect, molecular structure similar to a neuroleptic, receptor-binding profile similar to clozapine) that suggest its potential as an antipsychotic medication. The aim of the study was to investigate the antipsychotic potential of trimipramine in a controlled clinical trial comparing its antipsychotic efficacy with that of a neuroleptic.

METHOD

In a German multi-center, randomized, double-blind trial, the antipsychotic efficacy of trimipramine was compared with that of the phenothiazine neuroleptic perazine, using the Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Syndrome Scale (PANSS), and Clinical Global Impressions (CGI). Antidepressant efficacy of both agents was measured by use of the Bech-Rafaelsen Melancholia Scale (BRMES). Ninety-five patients with acute schizophrenia (DSM-III-R) and a BPRS total score > 40 at baseline were treated with either 300-400 mg trimipramine or 450-600 mg perazine for 5 weeks.

RESULTS

Therapeutic equivalence of both treatments (in the dosages used) could not be demonstrated (change in BPRS total score, per-protocol [PP] analysis, one-sided equivalence testing). However, intention-to-treat (ITT) as well as PP analysis showed a statistically significant decrease in the BPRS total scores in both treatment groups (PP: trimipramine, 56.5 +/- 9.8 to 44.1 +/- 17.9; perazine, 56.4 +/- 10.8 to 37.9 +/- 12.9). Significant decreases in all BPRS and PANSS subscores as well as CGI results and response rate support the antipsychotic efficacy of trimipramine. The BRMES total scores significantly decreased in both treatment groups without showing a significant difference between the two agents. Trimipramine was better tolerated than perazine and did not elicit extrapyramidal symptoms.

CONCLUSION

Trimipramine failed to exhibit therapeutic equivalence to perazine in the dosages used. However, there was evidence of a substantial antipsychotic effect of trimipramine. It may be a useful medication if depressive symptoms in psychotic patients require antidepressant treatment or if other antipsychotics cannot be administered.

Perazine for schizophrenia

BACKGROUND

Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia which has a reputed low level of extrapyramidal side-effects. However, its use is restricted in the sense that - to the best knowledge of the reviewers - it is only marketed in Germany, Poland, Yugoslavia and the Netherlands.

OBJECTIVES

To examine the effects of perazine for those with schizophrenia, and schizophrenia-like psychoses.

SEARCH STRATEGY

Electronic searches of the Cochrane Schizophrenia Group's register which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile were undertaken. References of all included studies were searched for further trials. Pharmaceutical companies and authors of trials were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared perazine with other treatments for people with schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by two reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. Data were excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the Relative Risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, weighted mean differences were calculated (WMD). All data were inspected for heterogeneity.

MAIN RESULTS

Six trials with a total of 288 participants are included. According to only one trial with 95 participants perazine appeared superior to active placebo (trimipramine) at five weeks for the outcome of 'no important global improvement' (n=95, RR 0.6, CI 0.3-0.9, NNT 4, CI 2-17), but there was no difference in various measures of mental state. The side-effect risk of perazine compared to placebo could not be estimated because they were not reported. Five small trials including only 193 participants which compared perazine with other antipsychotics were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible in most occasions. A similar number of participants receiving perazine or comparator antipsychotics left the studies early (n=193, RR 0.9, CI 0.5-1.4). The results on efficacy were controversial and need further assessment by randomised controlled trials. No obvious differences in adverse events between perazine and other antipsychotics could be derived from these limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a way usable for meta-analysis, but three small comparisons with the atypical antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n=111, RR 0.3, CI 0.1-1.1), dyskinesia (n=111, RR 0.5, CI 0.1-3.5), parkinsonism (n=81, RR 1.2, CI 0.5-2.8) or tremor (n=40, RR 0.8, CI 0.3-2.3) with perazine.

REVIEWER'S CONCLUSIONS

The number, size and reporting of randomised controlled perazine trials is insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics, and this should be clarified in larger, well-designed trials.

[Neuroleptic malignant syndrome--case report]

We have reported the case of a 65-year-old woman treated with neuroleptics because of organic delusive disturbances. She was treated for about one month with risperidone (Rispolept) and perazine (Pernazinum). Around ten days before the patient was admitted to this ward, the following had been observed: rise in temperature up to 40 degrees C, progressive weakness and blood pressure (RR) fluctuationis. Despite the applied treatment, the patient died during the fourth of hospitalization on this ward. The diagnosis of neuroleptic malignant syndrome was made on the basis of the clinical picture accomplished whole of biochemical, figurative tests as well as on the conducted differential diagnostics.

Neuroleptics normalize increased release of interleukin- 1 beta and tumor necrosis factor-alpha from monocytes in schizophrenia

Some recent reports show that schizophrenia is accompanied by changes in lymphocyte activity. This study investigated the activity of monocytes by determining their release of interleukin- 1 beta (IL- 1 beta) and tumor necrosis factor-alpha (TNF-alpha). Monocytes were immunomagnetically isolated from the peripheral blood of schizophrenic patients before and after neuroleptic medication and stimulated by lipopolisaccharide (LPS) in vitro. The monocytes of schizophrenic patients released significantly higher amounts of IL- 1 beta and TNF-alpha than those of healthy controls. Treatment with the typical neuroleptics haloperidol and perazine decreased the release of IL- 1 beta and TNF-alpha to the control levels. The study has shown that the activity of monocytes is increased in schizophrenia and that neuroleptic treatment normalizes this activity.

Relevance of liver enzyme elevations with four different neuroleptics: a retrospective review of 7,263 treatment courses

Data on liver enzyme elevations were collected in a retrospective study of 7,263 treatment courses with haloperidol, clozapine, perphenazine, and perazine. Charts of 233 patients hospitalized between 1980 and 1992 at Tübingen University Psychiatric Clinic were selected because clinically relevant increases of liver enzymes had been detected during monotherapy with one of the four examined neuroleptics. At least one hepatic enzyme (mostly alanine aminotransferase [ALAT]) exceeded the established reference range of 3-fold elevations of ALAT, aspartate aminotransferase, gamma-glutamyl transpeptidase, and glutamate dehydrogenase and 2-fold elevations of alkaline phosphatase (AP) during monotherapy with clozapine in 15%, perazine in 7.6%, perphenazine in 4%, and haloperidol in 2.4% of the cases. If all liver enzyme abnormalities with any elevation greater than the conventional upper limits are considered, incidences were as follows: clozapine, 78%; perphenazine, 62%; perazine, 59%; and haloperidol, 50%. Testing for overall differences within the four neuroleptics resulted in significantly different incidences of liver enzyme elevations (chi2 test,p < 0.0001). Threefold increases of AP (>540 U/L) were seen in three patients receiving haloperidol (0.3%) only. Twofold increases of AP (>360 U/L) were distributed as follows: clozapine, 1%; haloperidol, 0.8%; perazine, 0.3%; and perphenazine, 0.1%. Only in the group with 1-fold elevations of AP (>180 U/L) were the differences within the drug regimens significant (clozapine, 40.3%; haloperidol, 33.2%; perphenazine, 23.4%; and perazine, 23.1%; chi2 test, p < 0.0001). In the period under study, no instance of icterus occurred.

[Fatal poisoning with clozapine and perazine. A case report]

An intoxication following an apparent overdose of clozapine (Leponex) and perazine (Taxilan) is reported. There was a wide range of variation in postmortem blood and tissue concentrations of clozapine, desmethyclozapine and perazine. Clozapine/norclozapine blood and tissue ratios and perazine-pill-fragments in the gastric content could be used as a sign of suspected acute clozapine and perazine overdose.

Residual symptoms and P300 in schizophrenic outpatients

A reduced P300 amplitude has often been found to be related to schizophrenic psychopathology. It is still unclear, however, whether this relationship is trait- or state-dependent. We investigated 88 stabilized schizophrenic outpatients during a 2-year follow-up period. Multivariate analyses revealed that patients who had reduced P300 amplitudes showed pronounced residual symptoms, especially thought disorder (Brief Psychiatric Rating Scale). Intraindividual changes in that psychopathology were not correlated to corresponding changes of the P300 amplitude, so the relationship between schizophrenic psychopathology and P300 amplitude appears to be, at least in part, trait-dependent. A reduced P300 amplitude may characterize a subgroup of schizophrenic patients with a disposition to cognitive disturbances and incomplete remissions.

"Sunbath polyneuritis": subacute axonal neuropathy in perazine-treated patients after intense sun exposure

This article aims at drawing attention to the peculiar association of intense exposure to sunlight and subacute development of sensory neuropathy which was seen in 7 psychiatric patients treated with the phenothiazine derivative, perazine. Three patients additionally developed bilateral VII nerve palsy. Symptoms followed a monophasic course with almost complete remission. Routine neurophysiology suggested axonal neuropathy confirmed by sural nerve biopsy in 1 patient. A toxic origin of neuropathy is supposed, possibly induced by phenothiazine photoproducts, which may cause cell damage via lipid peroxidation.

Dysmorphophobia: differential-diagnostic aspects

The case of a patient presenting with a depressive-suicidal syndrome and dysmorphophobia, which also showed a delusional character, is discussed concerning the differential-diagnostic difficulties. The nosology of the disorder is discussed especially regarding the variants in the new classification systems.

A unique case of tardive dystonia induced by short-term therapy with perazin

Perazin is a piperazine derivative of phenothiazine with higher affinity for the D2 than the D1 receptor. We observed a 43-year-old woman who developed blepharospasm and oral hyperkinesia as a tardive dystonic syndrome after short-term treatment with perazin. She had never taken any other neuroleptic medication and all known forms of secondary dystonia were ruled out. We were unable to find any previous reports of perazin-induced tardive dystonia.

Schizophrenics with small P300: a subgroup with a neurodevelopmental disturbance and a high risk for tardive dyskinesia?

Schizophrenics with a neurodevelopmental disturbance resulting in micro- and macroanatomical cortical abnormalities are supposed to form a subgroup clinically characterized by low premorbid adjustment, early onset, incomplete remission, poor outcome, male predominance and high risk for tardive dyskinesia. A small amplitude of the event-related P3 (P300) potential could be a marker of this subgroup, because the cortical neurons and their orderly laminar arrangement are crucial for the electrogenesis of P3. In a 2-year follow-up study, auditory evoked P3 was recorded in 89 stabilized schizophrenic outpatients. Patients who developed tardive dyskinesia during the follow-up had smaller P3 than matched controls. Furthermore, a small P3 was associated with low premorbid adjustment, pronounced residual symptoms, low relapse rate, and male predominance. These findings indicate that schizophrenic patients with a reduced P3 have a higher risk of developing tardive dyskinesia and correspond clinically to a schizophrenic subgroup with a supposedly neurodevelopmental disturbance.