Serum concentrations of the isomers of clopenthixol and a metabolite in patients given cis(Z)-clopenthixol decanoate in viscoleo

Cis(Z)-clopenthixol decanoate in Viscoleo (Sordinol Depot, Cisordinol Depot, Clopixol Inj.) was given intramuscularly to nine schizophrenic patients with dosage intervals of 1 or 2 weeks. Serum concentrations of the two geometric isomers of clopenthixol and its N-dealkyl metabolite were recorded in two successive dosage intervals. Significant correlations were found for dose vs area under the serum concentration curve and vs serum concentrations measured on individual days. The last mentioned concentrations are good measures of the area under the serum concentration curve, which expresses the drug load of the patient. The serum concentration curves in two successive dosage intervals were very similar. Maximum serum concentration was seen 5-7 days after injection and the mean maximum/minimum fluctuation was 1.6 with the 2-week dosage interval. The finding of very low amounts of the trans(E)-isomers of clopenthixol and the N-dealkyl-metabolite shows that isomerization of the cis(Z)-compounds into the corresponding trans(E)-isomers does not take place within the organism.

A depot neuroleptic withdrawal study neurological effects

A double-blind withdrawal trial in 41 chronic schizophrenic outpatients was carried out over 6 months. Depot neuroleptics (fluphenazine decanoate or flupenthixol decanoate) were compared with placebo to evaluate neurological side effects during continued therapy and during withdrawal. The drugs were significantly more effective than placebo in preventing relapse and rehospitalization. In the placebo group 62% relapsed compared to 27% in the drug group. A difference was observed in the occurrence of extrapyramidal symptoms (EPS) between the neuroleptics in the study. Akathasia was observed in 9/38 (23.7%) cases, significantly more frequent in the fluphenazine decanoate group. Tardive dyskinesia (TD) was observed in six cases (15.8%); four cases existed at the start of the study and two others were observed after 3-6 weeks of withdrawal. There was no relation between TD symptoms and relapse. There was a significant decrease in the EPS scores during the placebo treatment and also a significant weight decrease.

Steady-state serum concentrations after cis (Z)-flupentixol decanoate in viscoleo

Serum concentrations of cis(Z)-flupentixol have been measured in patients on cis(Z)-flupentixol decanoate injections during successive dosage intervals of 2-4 weeks. The calculation of the fluctuation of the serum concentration in the dosage interval indicates that each individual patient should have his own dosage interval. For the 2-week group a significant correlation was found between weekly dose and preinjection concentration (r = 0.79) although an interindividual variability of X 4 was found. For this group the relative within-patient variation in the pre-injections concentration was calculated to be 9.6%, showing that a constant dosage regimen in the individual patient leads to an almost constant drug load.

Lithium + L-tryptophan compared with amitriptyline in endogenous depression

Endogenously depressed in-patients were treated for four weeks with either lithium + L-tryptophan (N = 22) or amitriptyline (N = 21) in an open study. Before and weekly during treatment the patients were evaluated by means of Hamilton rating scale, and blood samples were collected for determination of serum concentration of lithium, or amitriptyline and nortriptyline. Both groups responded significantly and the two treatments were not significantly different in antidepressive efficacy. No significant correlation could be demonstrated between clinical improvement and steady-state serum drug levels. From this study it appears that lithium combined with L-tryptophan may be effective in the treatment of endogenous depression.

Amitriptyline and nortriptyline excretion in human breast milk

Simultaneous blood and milk samples were obtained from a 30-year-old woman who was on sustained release amitriptyline, and the concentrations of amitriptyline and the active metabolite, nortriptyline, were estimated by GLC. Serum and milk concentrations were similar with a slight tendency for the amitriptyline concentrations to be higher in milk. Calculation of the transfer of drug from the mother to the baby showed that the baby received an amitriptyline dose which was about one hundredth the dose given to the mother. No active drug could be estimated in the baby's serum and the baby showed no clinical signs which could be drug related.

Serum concentrations of cis(Z)-flupentixol and prolactin in chronic schizophrenic patients treated with flupentixol and cis(Z)-flupentixol decanoate

Nine chronic schizophrenic patients selected from three hospital departments were treated with flupentixol (orally and IV) and cis(Z)-flupentixol decanoate in Viscoleo (IM) in a three-phase pharmacokinetic study. Oral administration (single and repeated dosage) showed a relatively slow absorption with maximum serum concentration around 4 h after administration. Intravenous injection indicated multicompartment kinetics for cis(Z)-flupentixol. The biological half-lives calculated after the different doses were the same, indicating that the pharmacokinetics of cis(Z)-flupentixol does not differ between single and repeated administration and does not change when moderately higher doses are given. The bioavailability of orally administered cis(Z)-flupentixol was calculated to be about 40% with IV injection as reference. After IM administration maximum serum concentration was seen between 4 and 10 days in most patients. Calculation of a disappearance half-life gave very variable results, indicating that the release of the drug from the oil depot is not a monoexponential process. The intramuscular depot had a much lower bioavailability than IV injection, which means that steady state has not been obtained after 8 weeks of depot treatment. Serum prolactin concentrations were elevated during neuroleptic treatment, but no correlation was found between prolactin concentrations and the serum concentrations of cis(Z)-flupentixol. A correlation between the changes in clinical ratings and concentrations of cis(Z)-flupentixol or prolactin was not found.

A depot neuroleptic withdrawal study. Plasma concentration of fluphenazine and flupenthixol and relapse frequency

A double-blind withdrawal trial in 41 chronic schizophrenic outpatients was carried out during 6 months. Depot neuroleptics (fluphenazine decanoate or flupenthixol decanoate) were compared with placebo to evaluate clinical and neurological effects during continued therapy and during withdrawal. The drugs were significantly more effective than placebo in preventing relapse and rehospitalization. In the placebo group 62% relapsed compared to 27% in the drug group. There was a weak and nonsignificant tendency to a higher relapse frequency in the flupenthixol group compared to the fluphenazine group. After withdrawal for 6 months, plasma levels for fluphenazine were detectable. Plasma levels for flupenthixol were not detectable after 9 weeks of withdrawal. The differences in the plasma levels may possibly explain the difference in relapse rate between the two depot neuroleptics. Furthermore, it was found that the patients who relapsed during fluphenazine treatment had a significantly lower plasma level of the drug than patients who did not relapse during treatment. The results from this study provide some information on the therapeutic levels of fluphenazine and flupenthixol in schizophrenic patients.

Radioisotope washout technique as a routine method for selection of amputation level

In 36 amputations of the lower extremity the local skin perfusion pressure was measured preoperatively by an isotope washout technique. The result served as a guidance in the selection of amputation level. An overall healing rate of 94 per cent was found with 64 per cent of the amputations being below the knee. Thus, the isotope washout technique, used routinely, gives a reliable preoperative assessment of the chances of wound healing following below-knee and above-knee amputations.

Preliminary studies on the absorption, distribution, metabolism, and excretion of THIP in animal and man using 14C-labelled compound

Distribution of radioactivity in rats, serum levels in human volunteers and rats and elimination of radioactivity in volunteers, rats, and mice following oral administration of 14C-labelled THIP have been investigated. Peak values of radioactivity in the organs and in serum were seen half an hour after administration, indicating a rapid absorption. Highest concentrations of radioactivity were found in the kidneys, but radioactivity was seen in all investigated tissues including the brain. The radioactivity was mainly excreted with urine (84-93%). Thin-layer chromatography of urine from volunteers, rats, and mice showed that most of the excreted radioactivity corresponds to unchanged THIP. Three metabolites were found in urine from rats each in amounts of 2-7% of total dose given. Two of these metabolites were also found in urine from the volunteers in amounts of 30-35% and greater than 2%, respectively, and in urine from mice in amounts of 21% and 6% of the total dose, respectively. No radioactivity corresponding to unchanged THIP was found in faeces indicating complete absorption of THIP following oral administration. One of the metabolites, the main one in man and mouse, seemed to be glucuronic acid conjugate of THiP, but the chemical structure of the metabolites has not yet been established.

Effect of des-tyrosine-gamma-endorphin in tardive dyskinesia

The endorphin neuropeptides may have neuroleptic-like effects on dopamine function and may be antischizophrenic. Ten chronic psychotic patients with neuroleptic-induced tardive dyskinesia and parkinsonism received placebo and des-tyrosine-gamma-endorphin (DT gamma E). Drug effects on movement disorders and eye-blinking rates were assessed by blind evaluations of randomly sequenced videotapes made during standardized examinations before and 30, 60, and 120 minutes after each injection and at 24 hours postinjection on days of consecutive treatment. Changes in schizophrenic symptoms were evaluated openly with the schizophrenia subscale of the Comprehensive Psychiatric Rating Scale. There were no significant effects of DT gamma E on any parameter and no side effects. This suggests that DT gamma E, within the tested dose range, does not influence the pathophysiology of neuroleptic-induced dyskinesias or chronic schizophrenia or have neuroleptic properties. However, DT gamma E is well tolerated and should be tested with higher doses during prolonged treatment.

Vasopressin in anergic schizophrenia. A cross-over study with lysine-8-vasopressin and placebo

Sixteen out of 19 patients suffering from chronic anergic schizophrenia completed a placebo-controlled cross-over study with lysine-8-vasopressin (LVP), following a schedule of 1 week of placebo, 3 weeks of LVP, starting with 22.5 IU/day, gradually increased to 67.5 IU/day, and finally 4 weeks of placebo. The psychic state was evaluated with the Brief Psychiatric Rate Scale (BPRS), during weekly live interviews, and following videotaped BPRS interviews at the beginning and end of the LVP period, and at the end of the final placebo period. Symptoms of parkinsonism and tardive dyskinesia were also videotaped during a standardized examination at the same intervals. The videotapes were subsequently randomized and evaluated blindly. The results of liver interviews showed a significant (P less than 0.05) decrease in the BPRS anergic factor after 2 and 3 weeks of LVP treatment, but there were no changes in any single item, other BPRS factors, or the BPRS total score. The results of the videotape evaluations showed that the BPRS thinking disorder factor was significantly (P less than 0.05) decreased after 3 weeks of LVP, whereas the BPRS score was unchanged. No consistent changes in parkinsonism or tardive dyskinesia were found. Although side effects were few, six patients became agitated or aggressive during the LVP treatment. The beneficial effect on thought disorder and anergia, but the absence of global effects on the schizophrenic syndrome, illustrates the need for further research with other vasopressin analogues. The advantages and disadvantages of live and videotaped psychiatric interviews are also discussed.

Electrocardiographic and cardiovascular changes in cats and dogs caused by high doses of amitriptyline given as conventional tablets or a sustained release preparation

Electrocardiographic and haemodynamic changes have been compared in anesthetized cats and in conscious dogs after high doses of amitriptyline given as conventional tablets or as a sustained release form. Plasma or serum levels of amitriptyline and nortriptyline were determined. In anaesthetized cats tablets caused marked ECG changes in all 6 animals combined with pronounced acidosis in 3 of the animals. The sustained release form caused no electrocardiographic changes in 4 animals and moderate disturbances in 2 animals, without acidosis in any of the 6 cats. Almost identical haemodynamic changes were seen in both groups. The plasma levels did not indicate poorer absorption from one preparation than from the other. In conscious dogs tablets caused marked clinical signs including restlessness, sedation and convulsions (2 dogs). Pronounced electrocardiographic changes were seen in all 4 dogs. Bundle branch block developed in 3 dogs. The sustained release preparation caused slight to moderate sedation and no convulsions. Pronounced electrocardiographic changes without bundle branch block were seen in one dog. Moderate changes were seen in the remaining dogs. Acidosis was most pronounced after the tablets. The serum drug levels clearly show that the absorption is much slower after administration of the sustained release preparation than after tablet administration and that somewhat lower amounts of drug are absorbed from the sustained release preparation than from tablets. It is evident from the present studies, that administration of high doses of amitryptyline as a sustained release preparation causes less toxic manifestations than given as conventional tablets. Part of the explanation may be that less amitryptyline is absorbed from the sustained release preparation than from tablets because of the high dose (dogs), but the main reason is most likely that the absorption from the sustained release preparation is much slower than the absorption from tablets.

Concentrations of Cis(Z)-flupentixol in maternal serum, amniotic fluid, umbilical cord serum, and milk

A venous blood sample and an umbilical cord blood sample were obtained from five young women treated with the neuroleptic drug, cis(Z)-flupentixol decanoate in Viscoleo (intramuscularly) or flupentixol (orally) at the time of giving birth. In two cases amniotic fluid was also obtained, and from three of the mothers milk and simultaneous blood samples were obtained in the lactation period. Concentrations of the active drug, cis(Z)-flupentixol were measured in serum, amniotic fluid, and milk by radioimmunoassay. It was found that the concentration of the active drug in umbilical cord serum (fetal serum) was lower than that in serum from the mother--the ratio being about 0.24. Thus the amounts of drug reaching the fetus are low, but they cannot be considered unimportant. The concentrations found in milk were about 30% higher than the serum concentrations. However, the amounts of drug administered to the neonate with the milk are very low and, unless the neonate differs considerably from the adult as to sensitivity to or metabolism of this particular drug, they are of no importance.

Pharmacokinetics and pharmacodynamics of amitriptyline in depression

1. The therapeutic effect and pharmacokinetics of amitriptyline were assessed in thirty-five patients suffering from primary depressive illness during inpatient treatment. 2. Contrary to our previous study, no significant correlation was obtained between the plasma concentrations of amitriptyline, nortriptyline or total tricyclics with Hamilton rating score at 6 weeks or percentage improvement after 6 weeks treatment. 3. There was also no correlation with the plasma concentrations of tricyclics with the corrected subjective side-effects score. 4. A linear correlation (rs = 0.80; p less than 0.001) was observed between the plasma concentration of nortriptyline and decreased tyramine sensitivity, an index of noradrenaline reuptake blocking effect. 5. The corrected side-effect score during the trial correlated (r = 0.64; p less than 0.001) with Hamilton rating score at week 6, i.e. the patients who complained of more side-effects had less clinical benefit during amitriptyline therapy.

A clinical trial comparing sustained release amitryptyline (Saroten Retard) and conventional amitriptyline tablets (Saroten) in endogenously depressed patients with simultaneous determination of serum levels of amitryptyline and nortriptyline

The clinical effect of a sustained release preparation of amitriptyline has been compared with that of conventional amitriptyline tablets in a double-blind cross-over study with 24 patients suffering from endogenous depression. The sustained release preparation was given in a single evening dose (9 p.m.) of two thirds the total daily dose of conventional tablets, which was given in a three times-a-day regimen (8 a.m., 12 a.m. and 9 p.m.). Serum concentrations of amitriptyline and its active metabolite, nortriptyline, were determined. No difference was found between the two preparations as regards either clinical effect or side effects. No correlation could be shown between the clinical effects and the serum concentrations of amitriptyline and nortriptyline.