Dissimilar dosing with high-potency and low-potency neuroleptics

The authors studied high-potency versus low-potency neuroleptic dosing practices for 110 Boston-area psychiatric inpatients and compared the findings with the dosing practices reported in surveys of nearly 16,000 Veterans Administration patients. Mean chlorpromazine equivalent doses for the most common agents correlated strongly in both samples. Although frequencies of lower doses of both types of agents were similar, doses of potent drugs above the daily equivalent of 1 g of chlorpromazine accounted for more than 40% of prescriptions. The mean chlorpromazine-equivalent dose of popular potent agents (haloperidol or fluphenazine) was 3.54 times as high as that of popular low-potency agents (chlorpromazine or thioridazine). Potent agents are commonly used in mania and schizophrenia, often in relatively high doses, which may carry an excess of risk over unproven added benefit.

Within-individual variation in steady state plasma levels of different neuroleptics and prolactin

Eleven male chronic schizophrenics were given, serially, oral pimozide, fluphenazine, and flupenthixol; the two latter were also given intramuscularly as decanoates in oil. Oral haloperidol was given before and after each drug. Analysis of variance of steady state plasma levels of the different neuroleptics showed considerable within-individual variation in such levels, probably due to differences in absorption and metabolism and between routes of administration. The findings suggest that if a patient fails to respond to one neuroleptic, there may be good pharmacokinetic reasons for switching him to another belonging to a different group, or for giving the same neuroleptic by a different route of administration. The study also showed that previous administration of one neurololeptic may influence the steady state level of another. The various neuroleptics produced different effects on plasma prolactin levels.

Depot neuroleptics: the relevance of psychosocial factors--a United States perspective

The need for psychosocial strategies in the treatment of schizophrenic patients after discharge is discussed in terms of relapse rates associated with maintenance neuroleptic therapy in the United States and elsewhere. The history of drug and psychosocial treatment is reviewed, and the rationale of psychosocial treatment is explained. New psychosocial approaches are explored, including the "expressed emotion" concept, the possible influence of environmental stress conditions, and the use of family therapy and social skills training to lower relapse rates.

Depot fluphenazine: risk/benefit ratio

The risks and benefits associated with depot fluphenazine are reassessed by a review and critique of the literature, with an emphasis on controlled studies comparing depot to oral preparations. Specific gaps in our knowledge are noted and recommendations are made for future research.

The use of depot neuroleptics: clinical experience in the United States

The use of long-acting injectable preparations such as fluphenazine enanthate or decanoate can reduce patient noncompliance, but documenting this in a controlled research design is difficult. Several studies of relapse rates among patients receiving oral fluphenazine, depot fluphenazine, or placebo are reviewed. Factors that may explain the lack of significant differences among different drug treatments in preventing relapse are discussed. Indications are presented for the use of depot neuroleptics, and strategies for achieving minimum effective doses are reviewed. Adverse effects of depot medication are also discussed, so that the clinician may maximize the ratio of benefit to risk.

The risk/benefit ratio of depot neuroleptics: a Scandinavian perspective

The three developmental phases in the acceptance and use of depot neuroleptics are described. The practical advantages of these drugs are considered, as well as the extrapyramidal side effects that may result from oral or depot administration. Local (injection site) and other side effects of depot neuroleptics are discussed. Typical plasma drug concentration curves and receptor responses of depot neuroleptics are illustrated. Alternative use of oral drugs and strategies to increase the effectiveness of depot forms are presented. The depot neuroleptics used in Scandinavia today are discussed, and predictions are made regarding their use in the future.

Psychosocial relevance and benefit of neuroleptic maintenance: experience in the United Kingdom

The benefits of psychosocial intervention were studied in patients on maintenance neuroleptics who live in high face-to-face contact with relatives who have high levels of expressed emotion. This group is at high risk of relapse when maintained on neuroleptics without social intervention. Relatives of patients in the experimental group received three types of intervention: an educational program, a relatives' group, and family therapy. The goal of intervention was to reduce face-to-face contact and/or relatives' levels of expressed emotion. The results at 9-month and 2-year follow up indicate the benefits of psychosocial intervention, while pointing out the danger in discontinuing maintenance neuroleptics for patients who live in stressful family environments.

A dramatic behavioral response to thyrotropin-releasing hormone following low-dose neuroleptics

A dramatic improvement in mood and behavior after TRH occurred during treatment with low-dose neuroleptics in a patient with major depression and borderline personality disorder. This response was observed during both open and double-blind trials. The administration of TRH alone or with higher dosages of neuroleptics, was ineffective. Twenty other patients with major depression, including several with borderline personality disorder, were studied in an identical design but did not show similar improvement.

Intervals between long acting neuroleptics: outcome and re-admission variables

A drug monitoring programme has evaluated flexibility in the use of treatment intervals with Depot Fluphenazine. In this large group of schizophrenics over 30% receive injections at intervals of over 3 weeks or longer, with an overall relapse rate of 24%. Analysis of the intervals reveals in those who relapse, that 20% of cases increased their interval by an average of 7 weeks. Generally, there was an increase in intervals by the patients in the second year of treatment.

Blood and plasma kinetics of cis(Z)-clopenthixol and fluphenazine in psychiatric patients after intramuscular injection of their decanoic esters

Whole blood and plasma concentrations of active neuroleptic drugs were measured in eight schizophrenic outpatients who had received cis(Z)-clopenthixol decanoate in Viscoleo or fluphenazine decanoate in sesame oil by intramuscular injection. Whole blood and plasma concentrations were very similar, though there was a slight tendency for blood concentrations to be higher than plasma concentrations. Maximum concentrations appeared at 1 week after administration of cis(Z)-clopenthixol decanoate, whereas the highest concentrations after fluphenazine decanoate were seen at the end of the 3-week dosage interval. Some between-individual variation and a limited within-individual variation was seen.

Low-dose neuroleptic treatment of outpatient schizophrenics. I. Preliminary results for relapse rates

In an attempt to begin to establish minimum effective dosage requirements for the maintenance treatment of schizophrenia, we undertook a double-blind comparison of low-dose fluphenazine decanoate (1.25 to 5.0 mg/2 wk) with the standard-dose regimen (12.5 to 50.0 mg/2 wk) in outpatient schizophrenics. For the first 126 patients studied, cumulative relapse rates at one year for the low dose were 56% and for the standard dose 7%, a significant difference. Despite the fact that very little dyskinetic symptomatology developed in the sample as a whole, the low-dose treatment appeared to have a significant advantage in producing fewer early signs of tardive dyskinesia. Severity of relapse and total cumulative dosage were also considered.

Spontaneous orofacial dyskinesia and dopaminergic function in rats after 6 months of neuroleptic treatment

A syndrome of spontaneous orofacial dyskinesia was identified in groups of rats treated for 6 months with a wide range of neuroleptic drugs. Phenothiazines, thioxanthenes, and substituted benzamides were particularly likely to induce the syndrome. It was observed in the presence of a functional blockade of dopamine receptors and endured for at least 2.5 months after drug withdrawal. There was no relation between the syndrome and changes in striatal dopamine receptors, as indexed by the binding of tritiated spiperone and tritiated cis(Z)-flupenthixol. The syndrome parallels several of the features of clinical tardive dyskinesia, whose pathophysiology thus may not involve changes in the characteristics of striatal dopamine receptors.

Diabetic neuropathic pain: control by amitriptyline and fluphenazine in renal insufficiency

Seven patients with diabetes of ten to 24 years' duration and renal insufficiency were treated with fluphenazine and amitriptyline in an attempt to control severe pain in the extremities. Six patients had relief of pain within five days of initiation of therapy. One patient had no pain relief despite mood alteration. The relief of pain persisted whether renal function was stable or declining. This form of therapy is safe and as effective in patients with neuropathic pain and mild to moderate renal insufficiency as in patients with normal renal function.

Kinetics of oral fluphenazine disposition in humans by GC-MS

The disposition of fluphenazine was investigated in six healthy volunteers following oral administration (5 mg). Using a sensitive and specific GC-MS procedure plasma fluphenazine concentrations were measured up until 32 h after drug administration. Peak plasma concentrations varied widely (range: 0.26-1.06 ng/ml) and were observed at 2.8 +/- 0.5 h following fluphenazine administration. The apparent terminal elimination half-life of fluphenazine was 33.1 +/- 8.1 h. The area under the plasma concentration-time curve differed widely between subjects (range: 7.1-28.6 ng/ml h) suggesting large interindividual differences in the extent of fluphenazine presystemic elimination.

Tardive dyskinesia in psychiatric outpatients: a study of prevalence and association with demographic, clinical, and drug history variables

We examined 153 psychiatric outpatients, on a maintenance regimen of neuroleptics, for tardive dyskinesia (TD) and parkinsonism. Demographic, clinical, and drug history data were collected to assess whether any of these factors were significantly associated with TD. After initial univariate screening, significant variables were analyzed by multivariate statistical methods. Tardive dyskinesia was significantly associated with the use of high-potency or high-dosage neuroleptics and depot fluphenazine, whereas low-potency neuroleptics were negatively correlated with moderate TD. Age, but not sex, correlated significantly with TD, as did histories of incoherence, grandiose delusions, and teeth or denture problems. Parkinsonism and TD were strongly associated. Although the prevalence of TD was quite high, there were no severe involvements of any of the Abnormal Involuntary Movement Scale body areas.

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.

Fluphenazine decanoate and tardive dyskinesia: a possible association

The authors examined the charts of 22 outpatients who had received intramuscular fluphenazine decanoate and oral fluphenazine hydrochloride to assess the incidence of tardive dyskinesia. The severity of tardive dyskinesia was assessed with the Abnormal Involuntary Movement Scale (AIMS). Both the total dose and average daily dose of fluphenazine decanoate correlated significantly with high AIMS scores. There were also significant correlations of AIMS scores with total dose of antiparkinsonian medication and total dose of other neuroleptics. Total dose of antiparkinsonian medication correlated with total dose of fluphenazine decanoate. The authors discuss the clinical and physiological implications of these correlations.

Fluphenazine determination in human plasma by a sensitive gas chromatographic method using nitrogen detector

This report describes a sensitive gas chromatographic method with the use of a nitrogen detector for the determination of fluphenazine at therapeutic concentrations in human plasma. Fluphenazine was measured as its acetyl derivative. Perphenazine, a structurally similar phenothiazine, was used as an internal standard. The acetylated derivatives were identified by GC/MS. Within-day coefficient of variation of the method over the concentration range 0.5 to 10 ng/ml fluphenazine was 6.7%. Fluphenazine concentrations in the plasma of patients receiving the drug orally (as dihydrochloride) or intramuscularly (as decanoate) were measured. There were large interindividual variations both in plasma levels and half-lives of fluphenazine in different patients treated with the same doses.

A depot neuroleptic withdrawal study. A controlled study of the clinical effects of the withdrawal of depot fluphenazine decanoate and depot flupenthixol decanoate in chronic schizophrenic patients

A double-blind withdrawal trial in 41 chronic schizophrenic outpatients on neuroleptics was carried out during 6 months. Long-acting neuroleptics (fluphenazine decanoate or flupenthixol decanoate) were used in comparison with placebo to determine the value in maintenance therapy. Most patients had a rather low maintenance dose, about 12.5-25 mg fluphenazine decanoate or 20-40 mg flupenthixol decanoate every third week. Relapse was often characterized by a return of the dame symptoms as the patient had during his first schizophrenic attack. Drugs were significantly more effective than placebo in preventing relapse and readmission to hospital. 62% relapsed in the placebo groups as compared with 27% in the drug group. All patients on active substance and without relapse during the controlled study had their treatment discontinued for 24 months in an open follow-up investigation. This resulted in relapse of all patients but one, i.e. a final relapse frequency of 97%. A significant weight decrease was observed in the placebo group. The risk of withdrawal is discussed.

Iontophoretic studies on pallidal neurones and the projection from the subthalamic nucleus

The predominant response of pallidal neurones to gamma-aminobutyric acid (GABA), glycine and dopamine when applied iontophoretically, was inhibition of firing rate. With dopamine some excitatory responses were observed, this never being the case with GABA or glycine. Picrotoxin reversibly blocked neuronal responses to GABA but not glycine in fourteen cases. Strychnine abolished glycine evoked inhibitions in seventeen cells while not affecting GABA responses. A number of cells were responsive to a stimulus delivered to the subthalamic nucleus (s.t.n.), an electrode array being used to establish the specificity of response to s.t.n. stimulation. In eight out of fourteen cases there was a reduction of 40% or more in the inhibitory responses following stimulation, with picrotoxin applied iontophoretically. Strychnine, conversely, had no effect on the synaptically evoked inhibition at doses that exceeded those required to antagonize iontophoretically applied glycine. Similarly, fluphenazine and naloxone administered iontophoretically or intraperitoneally (I.P.) had no effect on eight cells. The results indicate the existence of a 'GABA-ergic' link in the projection from the subthalamic nucleus to the globus pallidus, though other transmitters, but not glycine or dopamine, may contribute to the observed synaptic responses.

Doctor's versus patient's judgement in the assessment of mixed anxiety/depressive illness. Implications for measurement of therapeutic response

The relationship of doctors' assessments to their patients' self-assessments was examined in a double-blind comparison of Motipress and Anafranil in patients suffering from mixed anxiety/depressive states. Significant differences between doctors' ratings were revealed which were largely parallelled by their patients' self-ratings done independently, suggesting differences between subgroups of patients within the whole population. Appropriate statistical analyses eliminated these factors in the data and showed that they did not affect the conclusions of a conventional statistical analysis of the two treatment groups as a whole; there were no significant differences between the major improvements associated with each treatment.

Clinical trial of amitriptyline and fluphenazine in diabetic peripheral neuropathy

Ten adult insulin-dependent diabetics with symptomatic peripheral neuropathy were treated with amitriptyline alone or in combination with fluphenazine hydrochloride. Nine of the subjects had a good result within 48 to 72 hours. Two patients reacted adversely to the medication. These medications appear effective in treating the discomfort associated with diabetic peripheral neuropathy.

Follow-up study of 281 schizophrenic patients treated with high dosage fluphenazine decanoate

281 newly admitted female schizophrenic patients were treated with high dosage fluphenazine decanoate intramuscularly, starting with 250 mg per injection together with antiparkinsonian and antidepressant drugs. On a set day the 3 groups 'with neuroleptics' (NL) (n = 54), 'without NL' (n = 152) and 'relapsed when without NL' (n = 42) were compared concerning age, diagnosis, hereditary disposition, first admission and readmissions, number of admissions and global judgement. From the differences no clear conclusion for practical clinical work could be obtained. The good tolerance is discussed using the list of side effects including tardive dyskinesia and laboratory data.

Tolerance to fluphenazine and supersensitivity to apomorphine in central dopaminergic systems after chronic fluphenazine decanoate treatment

Fluphenazine decanoate was administered chronically to rats on a schedule for which marked tolerance developed to acute fluphenazine effects on several parameters of dopaminergic neuronal function. DOPAC and HVA levels, indicators of dopaminergic activity, were quantitated in terminal areas of the mesocortical, mesolimbic and nigrostriatal systems. With this fluphenazine regimen tolerance developed not only in the nigrostriatal and mesolimbic but also in the mesocortical dopamine system to the elevation of metabolite levels induced by acute fluphenazine administration. Evidence was obtained that tolerance was functional rather than metabolic and was characterized by a large reduction in the accumulation of metabolites which normally follows a challenge dose of fluphenazine. Other experiments suggested that the results were not due to the effects of chronic fluophenazine on the noradrenergic innervation of the cortex and were not explained by altered catabolism or clearance of the dopamine metabolites. During withdrawal from chronic fluphenazine decanoate treatment supersensitivity to apomorphine developed in the striatum. The time courses of the disappearance of apomorphine supersensitivity and of the reversal of tolerance to a fluphenazine challenge were different.

Cerebrospinal fluid endorphins in schizophrenia

Opioid-receptor-active material, endorphins, has been measured in cerebrospinal fluid samples obtained from schizophrenics. A chromatographic procedure isolated the Fraction I endorphin which was quantitated in a receptorassay. At least two cerebrospinal fluid samples were obtained from each patient, at Day 0 with no medication and at Days 30 and 60 after medication with fluphenazine under standardized conditions. Three series of patients were included: acute schizophrenics (= 11); re-entry schizophrenics (n = 7) who have previously been treated with neuroleptics but were readmitted to hospital usually as a consequence of stopped medication, and chronic schizophrenics (n = 9) who had been without neuroleptics for at least 2 weeks prior to Day 0. At Day 0, 6/9 acute cases, 4/6 of re-entry and 2/9 chronic cases had endorphin levels above the range of healthy volunteers. The levels in chronic cases were significantly lower than those in acute cases. Treatment with neuroleptics significantly lowered the endorphin levels in acute cases. These results confirm and extend previous observations.

Long-term fluphenazine decanoate maintenance dosage requirements of chronic schizophrenic patients

Forty-seven schizophrenic out-patients, who were satisfactorily maintained on a depot injection of fluphenazine decanoate, and who received the injection every 28 days, were progressively withdrawn from medication by increasing the time interval between injections while maintaining the amount of of drug per injection. The rate of reduction varied with each patient depending on various factors such as environmental stress considerations, and the patient's wishes. Finally three injections at 8-weekly intervals were given before complete withdrawal. The follow-up period was 23.7 months with a standard deviation of 1.9. A relapse rate of 80% was found, 25 patients relapsing during the withdrawal phase and 22 patients after the drug had been completely withdrawn.

High dosage treatment with fluphenazine intravenously followed by depot injections in acute schizophrenia

13 acute schizophrenics were treated for 28 days firstly with fluphenazine infusion with doses up to 180 mg on an average of 5 days followed directly by an injection of 25 mg fluphenazine decanoate, repeated after an average of 16 days. The clinical effectivity of the medium-high infusion dose and the direct changeover from infusion to depot injection was examined. No serious side effects could be seen, the changeover happened without exacerbation of symptoms. The clinical effectivity came up to the usual therapy with normal high dosage after 28 days therapy, a somewhat more rapid deliverance of symptoms during the first days remained impressive.

Plasma fluphenazine and prolactin levels in schizophrenic patients during treatment with low and high doses of fluphenazine enanthate

The relationship between plasma prolactin (PRL) and drug levels in patients receiving neuroleptic drugs is of special interest in view of evidence that the PRL elevation induced by these drugs reaches its maximum at sub-therapeutic doses. Plasma PRL and fluphenazine (FPZ) levels were measured by radioimmunoassay (RIA) in each of 11 chronic schizophrenics (nine men, two women) during two 4-week periods of treatment with FPZ enanthate at a "High Dose' (250 mg per week) and a "Low Dose' (12.5 mg per week) given in random order. Plasma PRL levels were above normal in 9 of 11 subjects during the last week of Low Dosage. High Dosage resulted in PRL levels significantly greater than found during Low Dose treatment in 9 of 11 patients. Thus the PRL response had not reached its "ceiling" during Low Dosage in most patients. A significant correlation between PRL and FPZ levels was found in seven subjects; evidence that immunoreactive FPZ levels relate to an effect caused by blockade of dopamine receptors. The plasma FPZ pattern between injections during week 1 of Low Dosage was remarkably stable; High Doses produced an initial drug peak at 1--2 h and a secondary peak occurring on days 2--3 followed by a return to preinjection levels by day 7.

Low neuroleptic serum levels in patients receiving fluphenazine decanoate

The authors monitored serum levels of fluphenazine in nine patients following injections of fluphenazine decanoate ranging from 10 to 75 mg. Levels were detected by a radioreceptor assay based on the ability of the drug to complete with 3H-spiroperidol for binding to dopamine receptors in rat caudate membranes. Serum levels of fluphenazine were quite stable over a 2- to 3-week period following single intramuscular injections of the decanoate and correlated with injected dose. Following decanoate treatment serum levels of fluphenazine are substantially lower than levels observed for most other neuroleptics administered orally. This raises questions as to how fluphenazine decanoate can exert therapeutic actions.

Fluphenazine outpatient clinics: a pharmacist's role

Twenty-five schizophrenic outpatients were treated in a pharmacist-administered fluphenazine decanoate clinic for periods of up to 1 year. These patients had a significantly lower rehospitalization rate, a decrease in medication related side effects, and showed improvement in functional capacity. The results suggest that a pharmacist can be clinically beneficial to schizophrenic outpatients and may help to reduce the cost of treatment programs.

Plasma fluphenazine levels by radioimmunoassay in schizophrenic patients treated with depot injections of fluphenazine decanoate

1 Using a radioimmunoassay, plasma fluphenazine (FPZ) concentrations were examined in 33 schizophrenic patients during 38 intervals between injections of FPZ decanoate. Doses ranged from 12.5 to 150 mg and intervals from 1 to 5 weeks. At least three blood samples were taken between injections from each subject; also in 26 subjects additional samples were taken during the first 24 h post-injection. 2 FPZ was measurable in all plasma samples. 3 Each injection was followed by a rapid rise in plasma FPZ concentration to a maximum at 1-8 h. The height of this peak varied considerably. Within the next 12-36 h plasma FPZ fell to a level slightly above that found before injection and then remained stable until the next injection, thus confirming the steady release of FPZ from the depot over this period. 4 For the group, dose and mean plasma FPZ levels correlated strongly. 5 Despite this, there was a four-fold variation in plasma FPZ concentration among subjects receiving the same dose. 6 The FPZ level on the last day of an interval between injections was a satisfactory estimate of the mean FPZ level for the interval. 7 In one subject examined in this way, a positive correlation was found (r = 0.76) between plasma FPZ (by radioimmunoassay) and plasma prolactin levels.

Fluphenazine and social therapy in the aftercare of schizophrenic patients. Relapse analyses of a two-year controlled study of fluphenazine decanoate and fluphenazine hydrochloride

The ability of long-acting fluphenazine decanoate and oral fluphenazine hydrochloride to forestall relapse among newly discharge schizophrenic patients is examined in the context of high and low degrees of social therapy (ST). A total of 105 patients were randomly assigned to the various treatments and maintained under controlled conditions for two years or until relapse. Relapse rates for all treatments remained traditionally high. Relpase rates for long-acting fluphenazine decanoate and oral fluphenazine hydrochloride are nearly identical in the first year, indicating that drug noncompliance does not adequately explain early schizophrenic relapse. However, patients who received long-acting fluphenazine decanoate and ST have a reduced risk of relapse over time. Relapsers who received long-acting fluphenazine decanoate appeared more affectively disturbed than other relapsers, yet both groups were diagnostically and symptomatically equivalent prior to treatment. Personal discomfort and intrafamilial stress are important predictors.

Fluphenazine enanthate in the outpatient treatment of late paraphrenia

Fluphenazine enanthate parenterally was compared to an antipsychotic drug (haloperidol) given orally for the "crisis intervention" treatment of elderly outpatients with late paraphrenia. In the fluphenazine group, 11 of 13 patients improved, compared to only 3 of 13 in the oral drug group (p less than 0.01). The superiority of fluphenazine probably was attributable to improved compliance with the prescribed regimen by patients receiving parenteral depot medication. Despite the advanced age of the subjects, significant adverse drug effects were uncommon.